Covid Home Kits - Super Health Pharmacy NJ

Covid-19 Home kits Request:

Full Name: *

Phone Number: *

Date Of Birth: *

E-mail:

Gender: *

Male

Female

Address:

Please fill out the following insurance information from your insurance card. Please use the information from your prescription RX card (not your medical card). If you are 65+ or have a Medicare B (red, white and blue card), please input the information from that card into the last field or text us a picture of the insurance card at 732-934-6134

Medicare B

If you would like to request tests for any other immediate family members who have the same insurance information as you, please include each of their 1) First & Last Name (s) and 2) Date of Birth (s) herein. 8 tests will be provided per family member. IF your family member has different insurance, please complete a separate form for them.

Would you like pick up or delivery?

I will pick up my free tests

Please deliver my tests

How many tests per person would you like ?

Signature *This field is required.

I acknowledge I am allowed to get up to 8 tests per month from my insurance without any cost to me directly. I allow SUPER HEALTH PHARMACY to bill my insurance company to cover the cost of the at-home rapid covid test kits. By submitting this form, I acknowledge that this is a request and that if my insurance does not cover the tests, I will be notified accordingly.