Patient OTC COVID-19 Test Attestation Logo

  • Patient Request and Attestation for 8 At Home OTC COVID-19 Test Billing Documentation of Request

  • If you are interested in requesting up to 8 At Home OTC COVID-19 tests, please continue answering the questions below. If you are not interested you may leave this form request at any time. 

    Only those who have qualifying insurance that cover At Home OTC COVID tests are eligible to receive them. We will notify you if you have or do not have coverage for the tests, using the contact information you provide below. Thanks!

     

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  • WE ARE SORRY, BUT AT THIS TIME YOU DO NOT QUALIFY TO RECEIVE ANY AT HOME OTC COVID-19 TESTS BECUASE YOU DO NOT HAVE PRESCRIPTION INSURANCE. PLEASE CHECK BACK WITH US IF YOU BECOME ELIGIBLE FOR PRESCRIPTION INSURANCE OR IF PROGRAM CHANGES ALLOW FOR US TO DISPENSE AT HOME OTC COVID-19 TESTS TO THOSE WITHOUT PRESCRIPTION INSURANCE.

     

    THANKS!

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  • If we do not already fill prescriptions for you here at Save-Rite Drugs in Irvington, please fill in the appropriate information from your prescription insurance card. If you have questions for us, please contact us at 270-547-2855 and we can assist.

    Member ID:
    RX BIN:
    RX PCN:           
    RX Group:          

  • Please fill out as many children, grandchildren and minors as needed, between 1 and 5.

    Name:        
    Date of Birth:   Pick a Date    
               
                    

    Name:         
    Date of Birth:   Pick a Date  
           
         

    Name:         
    Date of Birth:   Pick a Date 
           
         

    Name:         
    Date of Birth:   Pick a Date   
             
       

    Name:         
    Date of Birth    Pick a Date   
             
       

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