For Agents - Your eTest

(For Agents) Order Form

Name (As it appears on your Medicare card)(Required)

First Name Last Name

What coverage does this person have?(Required)

Medicare Subscriber ID Number (Optional)

Enter your Medicare Subscriber ID Number exactly as it appears on your card.

Unfortunately, we are unable to accept your insurance at this time. We are working to add more insurance companies to our website. Please check back again soon.

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

Sex(Required)

Male

Female

Shipping Address (Where to send tests to)(Required)

Address Apartment, Suite, etc. (optional) City State ZIP Code

Email (Needed to process order)

Enter Email Confirm Email

Phone (Needed to process order)(Required)

Repeat Monthly Order

Keep 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.

Yes, please send me 8 FREE tests every month. I understand I can cancel at any time.

Agent Name(Required)

(For Agents) Order Form

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