Medi-Cal Patients: Request Your 8 At-Home Antigen Tests

FOR MEDI-CAL PATIENTS: PLEASE FILL OUT THE FIELDS BELOW TO REQUEST YOUR TESTS AND AUTHORIZE US TO BILL YOUR INSURANCE. YOUR ORDER WILL BE SHIPPED WITHIN 24 HOURS AFTER YOUR INSURANCE HAS APPROVED THE ORDER.

Insurance Name

Insurance Phone Number

Policy Number

Group Number

Subscriber First Name

Subscriber Last Name

Relationship to Patient

Subscriber Date of Birth

Insurance Street Address

City

State

Zip

Email

Message

Shipping information

First Name

Last Name

Company (Optional)

Address

City

State

ZIP