COVID-19 Over-the-Counter (OTC) Testing Member Reimbursement Form

• Member ID (Include 3-Digit Alpha Prefix) * -
• Group Number *
• Date of Birth *

• Member's Last Name *
• Member's First Name *
• Member's Middle Initial

• Member's Street Address *

• City *
• State *
• Zip Code *

PLEASE PROVIDE THE FOLLOWING INFORMATION FOR THE OVER-THE-COUNTER TEST KIT(S) YOU PURCHASED:

• Name of the test: *
• Manufacturer of the test (FDA-approved list): *
• Where was test purchased (e.g., CVS, Walgreens, Amazon.com)? *
• Test kit UPC or Barcode #: *

• Number of kits: *
• Number of tests per kit: *
• Date of purchase (MM/DD/YYYY): *

• Total cost: * $
• Includes tests for other covered family members? *
  • Yes
  • No

Please attach a legible copy of the receipt. *

Choose a file or files to attach * (File types accepted: jpg, txt, doc, docx, pdf, xls, xlsx, ppt, pptx, rtf, tiff, and tif)

To upload multiple files, hold down the CTRL key while selecting multiple documents then click open.

By typing your name below, you are signing this application electronically. I am stating that the information above is correct. Any person who knowingly files a statement of claim containing any misrepresentation or any false, incomplete or misleading information, may be guilty of a criminal act punishable under law and may be subject to civil penalties. In addition, I attest that any claims for reimbursement for over-the-counter COVID-19 antigen tests will be used for the patient named above for personal use and is not for employment purposes, has not been (and will not be) reimbursed by another source, and is not for resale.

• Signature *
• Date *
• Phone Number *

• Checking this box will send a copy of your form to the email address provided.

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