At-home COVID-19 Test Request Form

Please complete one form per each member’s request.

Tests will apply to the preferred brand tier of your formulary and will be subject to deductible (if applicable) and the below copays:

*This form is only to be used by members of the Kettering Health Prescription Benefit Plan. For other inquiries please contact the pharmacy directly.

"*" indicates required fields

Name*

First Last

Date of Birth*

Insurance Subscriber ID*

* Please complete one form per each member request

Home Phone

Cell Phone

Email*

Address*

Street Address City State / Province / Region ZIP / Postal Code

Quantity of COVID-19 Tests (Max 8/month)

Your Pharmacy Location*

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