At-Home (OTC) COVID-19 Test Order

This order form is for organizations authorized by the California Department of Public Health to order At-Home (Over-the-Counter, OTC) tests.

Note: This order form is intended for organizations outside of Los Angeles County.

Los Angeles County organizations can access at-home testing resources through LA County Department of Public Health. Please do not use this form; for more information, please visit LA County At-Home Testing Resources.

Planning for Tests

Tests must be stored indoors and temperature-controlled (Range 35.6-86°F)
Test brands vary and boxes may contain 1-4 tests.
Instructions for the specific test will be included in each box.
Plan to have a 4x4x6 foot storage space for each 1,440 tests.
Email confirmation is sent when an order is submitted and also when it is approved.
Please allow 1-3 weeks for delivery.

Please verify your order for accuracy before you submit.

By placing this order, you agree to the following

Tests in organizations will be distributed to people who are uninsured or have limited access to healthcare resources (or in schools and organizations that primarily serve children under age 18, distributed in accordance with CDPH guidance).*

Your organization CANNOT charge people for COVID-19 tests provided by the CDPH.

Your organization CANNOT bill patients' insurance for COVID-19 tests provided by the CDPH.

At-Home (OTC) Tests are self-tests. Tests must be self-performed and resulted by each individual (or their parent/guardian).

Organization Information

Organization Name

Is this a child care, camp, school, or other organization that primarily serves people under age 18?

Type of Organization

Are you a state agency ordering OTC tests for employee testing only?

My organization has previously received COVID-19 tests from CDPH.

Organization Point of Contact (Person Placing Order)

First Name

Last Name

Email Address

Phone Number

Verify Email Address

Delivery Point of Contact (Person Receiving the Shipment)

Provide direct phone number (cell phone is best) to coordinate delivery of testing materials
Be available at shipping address to receive during working hours

Delivery POC Same as Org POC

Delivery POC First Name

Delivery POC Last Name

Delivery POC Email

Delivery POC Phone

Must be the person's direct phone number (cell phone is best, no extensions)

Secondary Delivery Contact Name

Secondary Delivery Phone

Must be the person's direct phone number (cell phone is best, no extensions)

Delivery Information

Important: Please review and verify your address to avoid delays.

No P.O. Boxes; must be a street address
Must be in California
Delivery Point of Contact must be at the address to receive the shipment

Please consolidate orders when possible. Ship to a central location, like a headquarters or district office. If tests must be shipped to more than one location, submit a separate order for each address.

Attention

Street

Building/Suite

City

County

Zip Code

Additional Delivery Instructions

Receiving Hours

Test Information

Please order a 16-week supply for testing eligible participants at all locations for your organization.
Eligible participants are those that are uninsured, underinsured, or have poor access to medical care, or those at high risk of severe illness (immunocompromised, those over >65 years).
Please note: Routine COVID-19 testing is no longer required in non-high-risk and/or acute health care and long-term care settings.
2 tests may be in one box. Please order the total number of tests needed for each individual to receive two tests. E.g., for 500 people request 1000 tests.

What is the total population that your organization serves?

Total At-Home Tests Requested

Additional Comments, Explanations, or Requests:

Please verify your order for accuracy before you submit.

Once approved, orders cannot be changed or corrected