NCDHHS COVID-19 Testing Supply Order Form

NCDHHS COVID-19 Testing Supply Order Form

As of November 2023, the state supply of at-home COVID-19 test kits has been depleted. If your local health department or organization requires additional tests, free COVID-19 test supplies are available for bulk ordering through the Federal Test Distribution Program. This program requires sites to order tests through the Health Partner Order Portal (HPoP):

Sites without an existing HPoP account: Fill out this HPoP Registration Form so that an account can be created for you. You will then be emailed instructions on how to activate your account and order tests.

Sites with an existing HPoP account: Go to https://hpop.hhs.gov to place your COVID-19 test order. For step-by-step guidance on how to order tests in HPoP, view this document: COVID-19 Test Order Process via the Health Partner Order Portal (HPoP).

Prior to ordering you must register with the state

If you have not previously ordered tests from NCDHHS, please fill out this COVID-19 Testing Provider Registration Form. Once your registration is approved, you will be notified via email and added to the facility drop-down list for ordering.

Requestor Information

Order Point of Contact*

Order Point of Contact Phone*

Phone

Order Point of Contact Email*

Street Address*

Please note that we cannot ship to PO boxes

City*

Zip Code*

Special Delivery Instructions

Please include any special instructions for delivery

Is your Order Point of Contact information the same as your Delivery Point of Contact?*

Full Name, Phone Number, Email

Yes

Delivery Point of Contact*

Delivery Point of Contact Email*

Delivery Point of Contact Phone Number*

Phone

Which of the following testing Supplies are your requesting?*

At-Home Kits

At-Home Attestation

No-cost testing: Facilities may bill third-party insurance for administrative costs but should not bill for the cost of test or charge self-pay patients
To ensure the state can spread the limited available supply equitably amongst those in need, facilities should utilize these free tests primarily for individuals who are under/un-insured

By checking the box below you attest that your organization can meet the above requirements associated with the use of rapid antigen tests.

I attest that my organization can meet the requirements outlined above*

What is the total amount of tests you are requesting?*

Please request in number of tests, not kits or boxes. One at-home kit = 2 tests. (e.g. If you need 100 at-home kits, please request 200 total tests)

Please confirm the total amount of tests you are requesting.*

What populations will you be serving with these tests?*

Please check all that apply

Please describe*

Are there any other details about your request that you would like to share with the State?

Send me a copy of my responses

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