COVID-19 HOME ANTIGEN TEST INFORMATION
Please ll out this portion of the member reimbursement form only if you are requesting reimbursement for a COVID-19 home
antigen test. If you are requesting reimbursement for something else, you can skip this portion.
• Is this reimbursement for a COVID-19 home antigen test?
• Tests ordered online must have already shipped (not pending, not in process). Please do not request reimbursement until your tests
have shipped. Has your test shipped?
• Did you purchase the test before 1/15/22?
• Yes: If test was purchased before 1/15/22, was the test ordered by a physician or proctored?
• No: If test was purchased after 1/15/22, was the test ordered by a physician or proctored?
• Was the test authorized for emergency use or approved by the FDA?
• Was the test required by your employer?
• One box or kit may have multiple tests in it. For example, one box may have two tests in it. How many total tests were purchased?
• Have you already taken the test?
• If yes, where were the results determined?
• Who took the test? (Please include their name, MRN, and number of tests they took)
Please include the following documentation with your request:
• An itemized purchase receipt with test name, date of purchase, price, and number of tests.
• Photo of the QR or UPC bar code, cut out from the testing box.
• If your COVID-19 home antigen test is dated before January 15, include evidence of prescription or provider involvement.
I certify that my COVID-19 home antigen test(s) were purchased for personal use, is not for employment purposes unless required by applicable
state law, has not and will not be reimbursed by another source, and is not for resale.
Patient/Authorizing name (parent’s name if patient is a minor or legal dependent)
Patient/Authorizing signature (parent’s name if patient is a minor or legal dependent) Date signed
Best contact/telephone number
429780066 Page 4 of 4 02/14/2022
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