LA County Homebound COVID-19 Antigen Test Request Form (Eligible and Ineligible Sub)

LA County Homebound COVID-19 Antigen Test Request Form (Eligible and Ineligible Sub)

LA County Homebound Program

COVID-19 Antigen Test Request Form
The Homebound COVID-19 Antigen Test Distribution program offers an at-home rapid antigen test kit via mail to Los Angeles County residents who meet the following criteria:
- Are age 65 years or older OR
- Are homebound or unable to leave their home
If eligible, a COVID-19 Antigen Test kit is provided free for a limited time. This allows a person to test themselves at home and does not require sharing of test results with anyone, including the Department of Public Health.

The test kit will come with a postcard that provides instruction for steps to take after a positive COVID-19 test.

If you have been exposed to COVID-19 and are symptomatic, please reach out to your health care provider. If you are not able to reach your health care provider or do not have a healthcare provider, and have questions about COVID-19 and treatment options, please contact the Los Angeles County Public Health InfoLine at 833-540-0473 (7 days a week, 8:00 a.m. - 8:00 p.m) to see if treatment is right for you.

For additional information regarding access to COVID-19 antigen tests, please visit the following website: http://publichealth.lacounty.gov/acd/ncorona2019/covidtests/

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Please provide the following information to have your FREE test shipped to your home.
Recipient Name:*

First NameLast Name
Recipient Phone #:*
Please enter a valid phone number.Format: (000) 000-0000.
Recipient Email:*
example@example.com
YesNo

Preferred Contact's Name:*

First NameLast Name
Preferred Contact's Relationship to the Recipient: *
Preferred Contact's Phone #:*
Please enter a valid phone number.Format: (000) 000-0000.
Preferred Contact's Email:*
example@example.com
Recipient Address (this cannot be a P.O. Box):*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Suite/Unit (if applicable):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
City:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
State:*

Street Address

Street Address Line 2

CityState

Postal / Zip Code
Zip Code:*
Postal / Zipcode
Zip Code:**

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Thank you, please submit the form below.

You are not currently eligible.

Thank you for filling out our Homebound COVID-19 Antigen Test Request Form. Unfortunately, based on the details of the submission the current recipient is not eligible for our Homebound COVID-19 Antigen Program.

If you feel this notice is in error, please contact our customer support at communityhealthstation@lts.com.

Please visit our website to learn about other ways to access rapid antigen tests: http://publichealth.lacounty.gov/acd/ncorona2019/covidtests/how/.
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