Order Form - Medicare Precision

Fill Out The Form Below To Place Your Order For Your Free COVID-19 Test Kits

Make sure you have your Medicare card ready. Enter your information as shown on your Medicare card and the address you want your tests sent to.

Once your eligibility is approved, you should receive your tests within 3-7 working days.

** If you have insurance provided by an employer, you do not qualify for this program.

Name (As Displayed On Your Medicare Card)(Required)

First Middle Initial Last

Address(Required)

Street Address City State ZIP Code

Email(Required)

Enter Email Confirm Email

Phone(Required)

Date of Birth (MM/DD/YYYY)(Required)

Sex(Required)

Male

Female

Please Enter Your MEDICARE ID below exactly the same as how it is printed on your card. Straight Medicare or Traditional Medicare or Medicare Advantage Plans are accepted. See the sample ID.

Medicare ID (XXXX-XXX-XXXX)(Required)

Consent & Acknowledgement(Required)

By submitting I give EXPRESS WRITTEN CONSENT authorizing Precision Rx pharmacy / VRA Enterprises LLC to be my preferred provider for my 8 At Home FDA Authorized, Covid-19 Tests each month for the duration of the Public Health Emergency (PHE). These tests are provided at no cost to me and are 100% covered by Medicare.

Both boxes below must be checked in order for Precision Rx to process your order.

I am not currently confined to a skilled nursing facility

Consent & Acknowledgement(Required)

I accept and understand I will receive notice each month to continue receiving my no cost COVID-19 Tests provided by Medicare

Phone

This field is for validation purposes and should be left unchanged.