Health Box Request Form

Protect Your Family. Protect your Community

Medi-Cal Patients: Get your No-Cost Health Box Today!

FILL OUT THE FORM TO CONFIRM YOUR

ELIGIBILITY & CLAIM YOUR HEALTH BOX NOW.

YOU MAY REQUEST A HEALTH BOX EACH MONTH.

Let’s Get Your Wellness Kit – It’s Quick & Secure

(Takes about 2 minutes to complete)

(1/4)

Please enter in MM-DD-YYYY format

Where Should We Send Your Kit?

(2/4)

Qualification for NO-COST COVID tests is dependent on symptoms you're experiencing.

(3/4)

Helping You Get the Right Care:

If none please list none
If none please list none
If none please list none
If none please list none

Final Step: Finalize Your Wellness Kit Selection (4/4)

Wellness Kit 2026

Wellness Kit Offer - NO COST:

We offer our Health Box, which contains up to 7 OTC products completely covered by Medi-Cal. These products are: (4) OTC COVID Tests, Acetaminophen, Bacitracin, Vitamin D / Calcium, Chest Congestion Reliever, Vitamin C, Magnesium Supplement

(You will NEVER pay out of pocket for this service).

Before taking any medications or over-the-counter drugs, consult a physician for a thorough evaluation. Always seek the advice of a physician or other qualified healthcare provider with any questions regarding a medical condition. Do not take medication if you have a known allergy to it.

Clear
By signing this form, I authorize Stay Well US and its Preferred Pharmacy to use my information to fill and ship my prescriptions. I understand that my information will be protected under HIPAA and used only for the purposes stated above.

Your privacy is important to us. Under California law, you have the right to access, delete, or control your personal data. By submitting this form, you acknowledge that you have read and agree to our Privacy Policy. The information you provide is protected under HIPAA. By submitting this form, you authorize Stay Well US to use and disclose your Protected Health Information (PHI) solely for the purpose of processing your reorder and coordinating with our preferred pharmacy.

NEXT

STEPS TO RECEIVE YOUR HEALTH BOX:

Step 1. FILL OUT THE

ONLINE FORM

With your California Medicaid information

Step 2. ALLOW US TO

VERIFY

Your California Medicaid coverage so you can receive your test at no cost to you!

Step 3. :

RECEIVE YOUR HEALTH BOX

Once verified, your Health Box will be shipped directly to your address. You may request a new Health Box each month.

Eligibility Requirements:

YOU MUST HAVE:

  • Must have active California Medi-Cal coverage.

  • Must be a resident of California.

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