Order Checklist | Home Medical Equipment & Supplies


We know there's a lot of information you're supposed to include on a script. Next time you have to order medical equipment or supplies for your patient, use our easy Order Checklist to keep track. When you're ready to order, use our fax sheet or online order form!  




  1. Doctor National Provider Identification Number (NPI) 
  2. Patient First & Last Name 
  3. Patient Date of Birth 
  4. Patient Contact (phone number, address
  5. Patient Insurance Carrier & Member ID 
  6. Date Prescribed 
  7. Diagnosis (please provide the correct ICD-10 code) 
  8. Product Details: 
    • Size 
      • Urological supplies: french size
      • Wound supplies: dressing or wound dimensions 
      • Orthoses: height, weight, foot size, appropriate leg measurements
    • Quantity to be dispensed 
    • Product type & notes 
      • Urological supplies: please specify catheter type (straight tip, coude, hydrophilic) and if applicable, include lab records of patient history of UTI.  
      • wound supplies: please specify number of wounds, location of each wound, level of exudate (excretion) from each wound, and preference of dressing material. 
  9. Number of Refills/Length of Need 
  10. Prescriber Signature 


Once you are ready, fax your script to us at 1-888-616-2361.

Questions? Call us Monday - Friday from 9am - 6pm at 1-844-402-4344. 

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