Name

Medicaid Order FormDelivery Date

Order Date

Customer Name

Facility Name Phone

Item/Size / Qty / Sold By / Allowable
To size a brief or pull-up, measure the user's waist or hips (whichever is larger)
**Pull-Ups
  1. StayDry Pull-up - Medium
/ 20pkg/80cs / Max 150 pcs
  1. StayDry Pull-up - Large
/ 18pkg/72cs / Max 150 pcs
  1. StayDry Pull-up - X-Large
/ 14pkg/56cs / Max 150 pcs
  1. StayDry Pull-up - XX-Large
/ 12pkg/48cs / Max 150 pcs
  1. Prevail Per-Fit Pull-up - Medium
/ 20pkg/80cs / Max 150 pcs
  1. Prevail Per-Fit Pull-up - Large
/ 18pkg/72cs / Max 150 pcs
  1. Prevail Per-Fit Pull-up - X-Large
/ 14pkg/56cs / Max 150 pcs
  1. Prevail Pull-up - Youth/Small 20"-34"
/ 22pkg/88cs / Max 150 pcs
  1. Prevail Pull-up - Medium 34"-46"
/ 20pkg/80cs / Max 150 pcs
  1. Prevail Pull-up - Large 44"-58"
/ 18pkg/72cs / Max 150 pcs
  1. Prevail Pull-up - X-Large 58"-68"
/ 14pkg/56cs / Max 150 pcs
  1. Prevail Pull-up - XX-Large 68”-80”
/ 12pkg/48cs / Max 150 pcs
  1. Tena Pull-up - Small
/ 16pkg/64cs / Max 150 pcs
  1. Tena Pull-up Super - Medium
/ 18pkg/72cs / Max 150 pcs
  1. Tena Pull-up Super- Large
/ 18pkg/72cs / Max 150 pcs
  1. Tena Pull-up Super - X-Large
/ 15pkg/60cs / Max 150 pcs
**Briefs
  1. Stay Dry Brief - Medium
/ 24pkg/96cs / Max 200 pcs
  1. Stay Dry Brief - Large
/ 24pkg/72cs / Max 200 pcs
  1. Stay Dry Brief - X-Large
/ 20pkg/60cs / Max 200 pcs
  1. Prevail Per-Fit Brief - Medium
/ 16pkg/96cs / Max 200 pcs
  1. Prevail Per-Fit Brief - Large
/ 18pkg/72cs / Max 200 pcs
  1. Prevail Per-Fit Brief - X-Large
/ 15pkg/60cs / Max 200 pcs
  1. Nu-Fit Brief - Medium
/ 12pkg/96cs / Max 200 pcs
  1. Nu-Fit Brief - Large
/ 18pkg/72cs / Max 200 pcs
  1. Nu-Fit Brief - X-Large
/ 15pkg/60cs / Max 200 pcs
  1. First Quality Brief - Small
/ 16pkg/96cs / Max 200 pcs
  1. First Quality Brief - XX-Large
/ 12pkg/48cs / Max 200 pcs
  1. Tena Brief - Small
/ 12pkg/96cs / Max 200 pcs
  1. Tena Brief - Medium
/ 25pkg/100cs / Max 200 pcs
  1. Tena Brief - Large
/ 25pkg/100cs / Max 200 pcs
  1. Tena Brief - X-Large
/ 15pkg/60cs / Max 200 pcs
**Doublers
  1. Booster Pads
/ 100 case / Max 90 pcs
  1. First Quality Doublers
/ 52pkg/208cs / Max 90 pcs
  1. Dignity Doublers
/ 45pkg/180cs / Max 90 pcs
  1. Peach Doublers
/ 30pkg/180cs / Max 90 pcs
**Underpads
  1. Disposable Underpad 22”x36”
/ 15pkg/150cs / Max 180/mo
  1. Washable Underpad 34"x36"
/ 3 per pkg / Max 3/month
  1. Washable Underpad 17"x24" (Bahama & Stuart Plaid)
/ 3 per pkg / Max 3/month
**Gloves (100 per box)
  1. Latex Gloves□ powder □ powder-free (check size □ sm □ med □ lg □ XL)
/ PVT 2/mo / AFH 4/mo
  1. Nitrile Gloves□ powder □ powder-free (check size □ sm □ med □ lg □ XL)
/ PVT 2/mo / AFH 4/mo
  1. Vinyl Gloves□ powder □ powder-free (check size □ sm □ med □ lg □ XL)
/ PVT 2/mo / AFH 4/mo
  1. Stretch Vinyl Gloves□ powder □ powder-free (check size □ sm □ med □ lg □ XL)
/ PVT 2/mo / AFH 4/mo
Item/Size / Qty / Sold By / Allowable
**Inserts
  1. Belted Undergarment (Dignity)
/ 30pkg/120cs / Max 200 pcs
  1. Surety Shield
/ 30pkg/180cs / Max 200 pcs
  1. Prevail Nite Inserts PL-113
/ 16pkg/96cs / Max 200 pcs
  1. MoliMed - Mini
/ 14pkg/252cs / Max 200 pcs
  1. MoliMed - Midi
/ 14pkg/168cs / Max 200 pcs
  1. MoliMed - Maxi
/ 14pkg/168cs / Max 200 pcs
  1. Prevail Bladder Control Pads – Moderate
/ 20pkg/180cs / Max 200 pcs
  1. Prevail Bladder Control Pads – Moderate Long
/ 16pkg/144cs / Max 200 pcs
  1. Prevail Bladder Control Pads – Maximum
/ 48pkg/192cs / Max 200 pcs
  1. Poise Moderate
/ 66pkg/264cs / Max 200 pcs
  1. Poise Light
/ 30pkg/180cs / Max 200 pcs
  1. Tena Dry Comfort Day
/ 44pkg/88cs / Max 200 pcs
  1. Tena Dry Comfort Day Light
/ 24pkg/144cs / Max 200 pcs
  1. Tena Dry Comfort Heavy Day
/ 40pkg/80cs / Max 200 pcs
  1. Male Guard
/ 52pkg/208cs / Max 200 pcs
**Personal Care (Items 58-68, choose up to two free with order of incontinence products)
M.D. Medical's Complimentary Items (not covered by DSHS)
  1. A & D Ointment
/ 4 oz / Choose up to 2 total… Mix and Match!
  1. Bibs Non-Waterproof
/ 13 oz
  1. No Rinse Hair and Body Shampoo
/ 1 ea
  1. Odor Eliminator Bye Bye
/ 7 oz
  1. PeriGuard Skin Protectant Ointment
/ 3.5 oz
  1. Provon Body and Hair Shampoo
/ 4 oz
  1. Provon Moisturizer Lotion
/ 8 oz
  1. Stay Dry No Rinse Peri Wash
/ 8 oz
  1. THERA Dimethicone Body Shield Treatment
/ 4 oz
  1. THERA Calazinc Body Shield
/ 4 oz
  1. Wipes
/ 64/box
**DME (Items 69-77 may be covered by DSHS and/or Medicare with a doctor's approval)
  1. App Pump and Mattress
/ 1 ea / Per Rx
  1. Hospital Bed
/ 1 ea / Per Rx
  1. Hoyer Lift
/ 1 ea / Per Rx
  1. Lift Chair
/ 1 ea / Per Rx
  1. Cane
/ 1 ea / Per Rx
  1. Walker
/ 1 ea / Per Rx
  1. Wheelchair
/ 1 ea / Per Rx
  1. Bedside Commode
/ 1 ea / Per Rx
  1. Enteral Pump
/ 1 ea / Per Rx
**Special Request

Caregiver certification: I certify that the items ordered are medically necessary and I am authorized to place orders for the person listed as "customer."

Signature: Printed Name: Date:

7687 S 180th St., Kent, WA 98032 * 1-800-892-1750 * Fax (425) 867-5087Page 2