Buy online Prescriber order form Item RX-FORM-REQUEST Referral Name Contact # Patient Name * Phone * DOB Day12345678910111213141516171819202122232425262728293031MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberYear20262027 Patient Address Weight Height Insurance Name Policy No INCONTINENCE PRODUCTS — DX CODE REFILL # Items Disposable Chux Diapers Panties Liners Reusable Chux Bed Size Reusable Chux Chair Size Gloves Wet Wipes Disposable Chux — QTY (300 max) Diapers — QTY (250 max) Panties — QTY (5 max) Liners — QTY (5 max) Reusable Chux Bed Size — QTY (2 max) Reusable Chux Chair Size — QTY (2 max) Gloves — QTY (1 box max) Wet Wipes — QTY (1 box max) MOBILITY — DX CODE Items Heavy Duty Wheelchair Heavy Duty Rollator w/seat Heavy Duty Walker Rollator w/ Seat Standard Wheelchair Lightweight Wheelchair Walker w/ Wheels Quad Cane Standard Cane Crutches Walker w/o Wheels ADDONS — DX CODE Items With Seat & Back Cushion With Elevating Legrest Seat Belt BED & MATTRESSES — DX CODE Items Hospital Bed w/Mattress & Rails Bariatric Bed Gel Mattress Air Mattress Over-Bed Table Hydraulic Patient Lift BATH SAFETY — DX CODE Items Commode Transfer Bench Grab Bars Tub Rails Shower Stool Shower Head Shower Chair Toilet Rails Hand held ORTHOTICS — DX CODE Items Night Splints (LT/RT) Cam Boots (LT/RT) Crow Boot (LT/RT) Surgical Shoe (LT/RT) Custom Brace Diabetic Shoes Orthopedic Shoes Bone Stimulator Shoulder Brace Back Brace Abdominal Supports Hernia Brace Elbow Orthoses Knee Brace (LT/RT) Ankle Brace (LT/RT) Custom Made Inserts Toe Filler (LT/RT) RESPIRATORY THERAPY — DX CODE Items Nebulizer — Standard Nebulizer — Portable Pulse Oximeter Blood Pressure Monitor Dexcom/Freestyle Libre Device & Patches (CGM) MASTECTOMY — DX CODE Items Silicone Breast Prosthesis (LT/RT) Mastectomy Bra Mastectomy Bra — QTY EDEMA — DX CODE Items Knee Highs Thigh Highs Pantyhose Compression Stockings Lymphedema Pump / Sleeves Compression Stockings — QTY Dr * NPI Date * Day12345678910111213141516171819202122232425262728293031MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberYear20262027 Signature * Signature Rx & chart notes Attachment 2 Attachment 3 Attachment 4 Attachment 5 $0.00 Qty: Add to cart or Have insurance? We can bill Medicare, Medicaid or your private plan instead of you paying now. Send a request and we will check what your plan covers before anything is ordered — there is no charge for asking. Check my coverage Ships anywhere in the US We handle the insurance paperwork Talk to a person, not a robot Add to compare list Email a friend About this product I certify that the equipment and supplies I prescribed are medically necessary for this patient’s well-being: this is NOT prescribed as convenience equipment. In my professional opinion, the equipment is both reasonable and necessary in reference to the accepted standards of medical practice and treatment for this patient’s condition. SUBSTITUTION FOR THIS DEVICE IS NOT ALLOWED WITHOUT MY WRITTEN APPROVAL.How do I send this form?Fill it in and press “Send this order form”. If a fax is easier, send it to (718) 735-3444 — we still take forms by fax.What should I attach?The prescription and a chart note supporting it. Medicare will not pay without documentation, and a request without it stalls. Up to five files: JPG, PNG, PDF or Word.Do I need a diagnosis code for every section?No. Leave it blank if you do not have it to hand and we will confirm it with your office.Where do you deliver?Large equipment — wheelchairs, hospital beds, patient lifts — we deliver and set up across the five boroughs of New York City. Smaller items ship by courier within New York State or nationwide, depending on the item.Who do I call?(718) 735-3400, Monday to Saturday, 9 a.m. to 5 p.m. We speak English, Spanish and Russian.