Secure Order Form Fill out the form below to order your 8 FREE Covid-19 home tests. Or, if you wish to order by phone, call (844) 636-4233. Please have your Medicare ID card ready. MEDICARE ELIGIBILITY REQUIREMENTS: You are 100% COVERED if you have Medicare (Part B) or Medicare Advantage. You are NOT COVERED if you only have Medicare (Part A). Name (As it appears on your Medicare card)(Required) First Last Do not put middle initial. Do not add multiple spaces in between words or characters.Medicare Subscriber ID Number(Required) Enter your Medicare Subscriber ID Number exactly as it appears on your Medicare card. It should follow the format XXXX-XXX-XXXX. If you are entering a Medicare Advantage Member ID, please enter the Provider name in the same field in the following format "XXXXXXXXXXX PROVIDER NAME". If you have any difficulty or questions, please give us a call at 844-636-4233.Date of Birth (MM/DD/YYYY)(Required)MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Sex(Required) Male Female Shipping Address (Where to send tests to)(Required) Address Apartment, Suite, etc. (optional) City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Email (Needed to process order)(Required) Enter Email Confirm Email Phone (Needed to process order)(Required)Repeat Monthly OrderKeep your loved ones safe and stay ahead of the curve by testing regularly. Medicare will cover up to 8 Covid-19 home tests each calendar month. You can cancel this recurring service at any time. You will be shipped monthly ONLY if you check the box below, otherwise this will be a one time shipment. Yes, please send me 8 FREE tests every month. I understand I can cancel at any time.Agreement to Terms(Required)I have read and understand the Terms of Use listed on this website. I authorize Senior Covid Tests (Century Clinics) to be my preferred supplier for Medicare covered Covid-19 tests for the duration of the public health emergency. I understand that Medicare will only cover up to 8 Covid-19 OTC tests per calendar month. The insurance information I am providing is accurate and I am not intentionally providing false information which is a Federal crime. I acknowledge and agree PLEASE double check all form fields before submitting. Not following instructions will cause delay or cancellation without notice. If you notice an error after submission, please contact us or give us a call at (630) 381-6630. DO NOT ENTER FALSE INFORMATION OR SUBMIT MULTIPLE TIMES. ALL INFORMATION IS CHECKED AND VALIDATED BEFORE FULFILLMENT.
