Medicare Provided COVID Test Kits

Patient Acknowledgment and Consent

I hereby acknowledge that I am an individual who has Medicare coverage and have Medicare B coverage.

As of April 2022, I am entitled to 8 FREE FDA approved COVID-19 test kits per month as long as the order is in place.

If elected to receive the FREE kits, they will be sent to the address provided with NO copay, NO shipping charges and NO effect on your Medicare coverage.

I understand that I am ordering the 8 FREE test kits that I am entitled to and understand that the FDA approved test kits have a NO return policy.

This program is intended to help members detect early COVID-19 infections so that the member can seek timely care.

First Name

Last Name

Delivery Address

City

State

Zip

Date of birth

Contact Number

Medicare Number

I agree to the Patient Acknowledgement and Consent Form

Yes

I agree to receive 8 home test kits monthly on auto refill

Yes

Patient Signature

Yes, I accept the consent conditions.

Date