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COVID-19 Antigen Test Request Form

1.Introduction & Attestation

The LA County Department of Public Health’s (DPH) COVID-19 Antigen Test Distribution program officially sunset on February 28, 2025. DPH is offering antigen tests for a limited time to select sectors on a first come, first served basis until inventory is depleted.

To ensure we can distribute COVID tests to as many facilities as possible, test request orders may be limited based on available inventory.
  • Please be able to accept deliveries Monday-Friday 8 am to 5 pm.
  • You will receive an email from us with additional information and an estimated delivery date once the order is processed.
Attestation

I understand this is an agreement between the Organization and DPH. To receive COVID-19 testing supplies at no cost for use by the community in which it is located, the Organization agrees that it will adhere to the following requirements:

  1. The Organization must not sell or seek reimbursement for the testing supplies provided at no cost to the Organization for this or any previous requests.
  2. The Organization must provide the tests regardless of the recipient's ability to pay administration or related fees or coverage status. The Organization may not seek, and will have never sought, any reimbursement from the test recipient, including through balance billing.
  3. The Organization must have processes to ensure timely and proper acceptance of testing supplies. Those processes must include, but are not limited to, procedures for accepting delivery through commercial delivery services.
1.I attest that the Organization will agree to the above statements to be eligible for free antigen tests under DPH's distribution program.(Required.)
2.Enter the first and last name of the signer below, which will act as an e-signature affirming your attestation on behalf of the Organization.(Required.)