First Name Last Name Date of Birth Phone No. Address Insurance Information: Medicare Medicare ID # Advantage Plan Medicare Advantage Plan Carrier Name ID # Carrier Address for Claims Phone By electronically signing below, and initialing each line item, I am requesting (8) Eight Covid-19 at home Test Kits to be sent on a monthly basis to my home address From Denville Medical Health Center and Sports Rehab, located at 161 East Main Street, Denville, NJ 07834 I am an individual who participate in Medicare Part B or a Medicare Advantage plan I am requesting to receive (8) Eight FDA approved, authorized or cleared over-the-counter COVID-19 test kits on a monthly basis at no cost to me I am aware that my annual deductible, coinsurance and copayment will not apply to in receipt of these test kits, and that the Practice cannot and will not balance bill the beneficiary for any amount for the test kits above the amount which the Practice is paid by Medicare I will continue to receive this benefit of eight test kits per calendar month until the federal government ends the COVID-19 public health emergency I am aware that Medicare will not pay for more than (8) Eight test kits per month; if, through multiple requests to different health care providers participating in the Demonstration, I receive more than (8) Eight test kits in a calendar month, I may be responsible for out-of-pocket costs for these extra test kits. I am aware that I am not required to participate in the Demonstration, and I do not have to receive the test kits from Denville Medical Health Center and Sports Rehab and am aware that I will not receive any test kits until after I have signed this Request and Authorization form acknowledging that I want to receive these benefits from Denville medical Health Center and Sports Rehab. I am also aware that the I can cease participating in the Demonstration at any time by notifying the Company that I want to discontinue receiving test kits. 1976
