Inquiry Date: (mm/dd/yyyy)
Patient's Name:
Address: City, State, Zip Code:
Phone: Date of Birth: Social Security #:
Contact Name: Relationship:
Phone # :
Medicare #: Medicaid #:
Other Insurance #:
MD Name: Phone #:
MD Address: Fax #:

*The above information must be completed in order for us to successfully process the supplies ordered.  Prescriptions from doctors for supplies are accepted and are appreciated.

ITEMS COVERED BY MEDICARE ONLY:

Semi-electric Hospital Bed	Manual Hospital Bed with Rails and Mattress
Alternating Air Pressure Mattress	Gel Mattress	Foam Mattress
Alternating pressure pad	Hoyer Lift	Trapeze bar (for hospital bed)

Mobility and Rehabilitation:

	Wheelchair: 16 "    18 " (Standard)     20 "   22 "     24 "     Elevating Leg Rest     Folding Patient weight: lbs. Cushion: Reason:
Lightweight Wheelchair 16     18 (Standard)     20     22     24     Elevating Leg Rest     Folding Patient weight: lbs Cushion: Reason:

Cane:

Standard

Quad Cane: Narrow base Wide base

Walker (options):

	Standard (no wheels) Walker w/ Two wheels:          3" 5" Swivel Wheels Basket
Rollator (4 wheels, breaks, seat and basket) co-pay required Wheels: 3" 5" Swivel

Bathroom Aids:

Bedside commode Heavy-duty commode (if patient is over 280 lbs) Patient weight: lbs.

Incontinence supplies:

Catheter (indicate size):	Catheter Options: (Foley shown at left) Strait or Foley
Catheter insertion tray	Male external catheter (Texas)
Leg bag	Drainage bedside bag
Urinal	Bedpan

Diabetic Supplies:

Blood glucose meter/monitor

Boxes Test Strips (indicate name of monitor)

Boxes Lancets

Blood Glucose Monitor Test Solution

Alcohol Prep Supplies

General Medical Supplies:

Wound care supplies:
Gauze sponge	Tape	Bandage	Other dressings:

ITEMS COVERED BY MEDICAID ONLY:

	Wall grab bar: 12"     16"     18"     24"     32" (Note: this bar must be screwed into the wall; it does not work by suction)
Bathtub safety rail/Tub grab bar
	Shower Chair: Rectangular with a back Rectangular without a back Round without back
Bedside Table: Tilted Not Tilted
	Transfer Bench: Padded Unpadded
Raised Toilet Seat Raised Toilet Seat with a handle
Maximum number of boxes allowed per month: 2
	Boxes Adult Diapers/Briefs small medium large X-large
Boxes Protective underwear (pull-ups) small medium large X-large
	Boxes Absorbent Liners
Boxes Incontinence pads (single use chux)
	Boxes Gloves small medium large (if ordered for HHA, please pick up at our office)
Elbow protectors Heel protectors
	Compression stockings:  Knee high Thigh high
Digital Blood pressure monitor:	l

OTHER ITEMS OR COMMENTS:

We will process each order in a timely manner and needed supplies will be delivered to your home.  Wheelchairs, hospital beds and air pressure mattresses will not be covered by insurance if patient has ordered them in the past 5 years.  In case of no insurance coverage, MD/MR denials, HMO, or if a patient’s deductible has not been met, patient and/or family members are responsible for charges of supplies delivered. 

Within 1-2 business days, a Gentle Care representative will contact you to confirm your order and go over any important details, including product specifications and billing information.

*No orders will be processed without the patient’s signature (or equivalent) for confirmation.

I hereby authorize the above information to be true, that I am in need of the equipment and/or supplies stated and understand the above information about payment coverage.

Customer's signature: