All information provided through this website is HIPPA protected.
Requesting Individuals Information
First Name
Last Name
Name of Agency
Individuals Title
Phone Number
Please enter a valid phone number.
Email
An order confirmation will be sent to this email address.
Physician
First Name
Last Name
Office Contact
First Name
Last Name
Office Contact Phone
Please enter a valid phone number.
Office Email
example@example.com
Patient Name
First Name
Last Name
Patient Birth Date
-
Month
-
Day
Year
Date
Patient Case ID Number
ALL DME items require a written script, our team will reach out to the physician for the script. Please note a recent face-to-face must have been completed within the last 90 days.
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Favorites
Full Electric Bed
Basic Homecare Full-Electric Bed **Requires Prior Authorization
$
Free
Size
Twin
Twin XL
Full
Queen
King
Bed Disposal
Yes
No
Memory Foam Mattress
Self-Adjusting Air/Foam Mattress with Optional Alternating Pressure Pump. **Requires Prior Auth (can be used on your existing bed or the full electric bed)
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
**VivaLift Tranquil
**Requires Prior Authorization
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
**Afflovest
**Requires Prior Authorization
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Rollator Walker (With Seat)
Limit 1 per year
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Respiratory
Incentive Spirometer
Limit 1 per year.
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Flutter Valve/Acapella
Limit 1 per year. **Requires Prior Auth
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
*Nebulizer
**Requires Prior Auth
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
*Portable Nebulizer
**Requires Prior Auth
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
**Air Purifier
**Requires Prior Authorization
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
**Afflovest
**Requires Prior Authorization
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Mobility
Standard Offset Cane
Limit 1 per year.
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Quad Cane
Limit 1 per year
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Rollator Walker (With Seat)
Limit 1 per year
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Upright Walker
Limit 1 per year
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Transport Chair
**Requires Prior Authorization
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
**Standard Wheelchair
**Requires Prior Authorization
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Pride Mobility Victory 9
**Requires Prior Authorization
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Jazzy Elite ES Portable
**Requires Prior Auth
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Go-Go Elite Traveler
**Requires Prior Auth
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Jazzy Carbon
**Requires Prior Auth
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
**VivaLift Tranquil
**Requires Prior Authorization
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
VivaLift Legacy
**Requires Prior Auth
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
**Patient Lift
**Requires Prior Authorization
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Transfer Bench without Glide Rail
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Transfer Bench with Glide Rail
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Shower Stool
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Bed Assist Bar with Storage Pocket
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Step-2-Bed Rail
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Adjustable Bed Assist Rail
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Gripper Socks
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Gait Belt with Handles
*requires prior authorization
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Standard Gait Belt
*requires prior authorization
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Walker with Wheels
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Folding Walker
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Patient Turn and Transfer
Mobility to sit to stand device for transferring from Bed, Seat & Wheelchair **Requires Prior Auth
$
Free
Medical Supplies
Alcohol Surface Wipes
Limit 3 packages per month of either Alcohol Surface Wipes, Alcohol Prep Pads, or both. (brandnames may differ)
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Alcohol Prep Pads
Limit 3 packages per month of either Alcohol Surface Wipes, Alcohol Prep Pads, or both.
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Thermometer
Limit 1 thermometer per year
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Peroxide
Limit 3 per month
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Manual BP Monitor
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Nitrile Gloves
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Size
Small
Medium
Large
XLarge
Surgical Masks (Pack of 20)
Limit 9 per 6 months (12 total per year)
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Automatic BP Monitor
Limit 1 per year.
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Paraffin Bath (Hand Wax Unit)
$
Free
Paraffin Wax (5 Lbs)
$
Free
Rectangle Heating Pad
$
Free
Neck/Shoulder/Back Heating Pad
$
Free
Infrared Heating Pad
*Requires Prior Authorization
$
Free
Sheepskin Pad
$
Free
Position Cushions (Can select up to 3)
$
Free
Style
Back and Seat Cushion Set
Knee Cushion
Wedge Pillow
Gel Seat Cushion
Compression Socks
$
Free
IV Floor Stand
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Kangaroo Pump
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Shower Stool
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Bed Assist Bar with Storage Pocket
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Gripper Socks
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Gait Belt with Handles
*requires prior authorization
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Standard Gait Belt
*requires prior authorization
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Folding Cane with Flashlight
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Walker with Wheels
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Incontinence
Pull Ups for Men
More than 300 continence items per month will require a script. This total includes all wearable incontinence items such as insert pads, pull up briefs, and tabbed briefs.
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
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25
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28
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30
31
32
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34
35
36
37
38
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40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
Size
S
M
L
XL
XXL
Pull Ups for Women
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Size
S
M
L
XL
XXL
Unisex Briefs with Tabs
More than 300 continence items per month will require a script. This total includes all wearable incontinence items such as insert pads, pull up briefs, and tabbed briefs.
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
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25
26
27
28
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31
32
33
34
35
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40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
181
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
242
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
270
271
272
273
274
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
290
291
292
293
294
295
296
297
298
299
300
Size
S
M
L
XL
XXL
Incontinence Pads for Men
More than 300 continence items per month will require a script. This total includes all wearable incontinence items such as insert pads, pull up briefs, and tabbed briefs.
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
181
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
242
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
270
271
272
273
274
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
290
291
292
293
294
295
296
297
298
299
300
301
302
303
304
305
306
307
308
309
310
311
312
313
314
315
316
317
318
319
320
321
322
323
324
325
326
327
328
329
330
331
332
333
334
335
336
337
338
339
340
341
342
343
344
345
346
347
348
349
350
351
352
353
354
355
356
357
358
359
360
361
362
363
364
365
366
367
368
369
370
371
372
373
374
375
376
377
378
379
380
381
382
383
384
385
386
387
388
389
390
391
392
393
394
395
396
397
398
399
400
401
402
403
404
405
406
407
408
409
410
411
412
413
414
415
416
417
418
419
420
421
422
423
424
425
426
427
428
429
430
431
432
433
434
435
436
437
438
439
440
441
442
443
444
445
446
447
448
449
450
451
452
453
454
455
456
457
458
459
460
461
462
463
464
465
466
467
468
469
470
471
472
473
474
475
476
477
478
479
480
481
482
483
484
485
486
487
488
489
490
491
492
493
494
495
496
497
498
499
500
Level
Shields - Light
Guards - Maximum
Incontinence Liners for Women
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Size
Regular
Long
Level
Lightest (1)
Light (2)
Female Urinal
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Male Urinal
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Incontinence Pads for Women
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Size
Regular
Long
Level
Light (3)
Moderate (4)
Maximum (5)
Ultimate (6)
Ultra (7)
Underpads / Chucks
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Size
30x30"
36x36"
Cloth Underpads
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Size
30x36"
34x36"
Peri Wash
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Barrier Cream
Skin Protectant
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Type
Dermaseptin
Dimethicone
Periguard
Catheter
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Ostomy Bag
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Adhesive and Barrier Remover
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Personal Care Wipes
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Ostomy Odor Control
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Barrier Strip
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Beds/Mattresses/Accessories
Full Electric Bed
Basic Homecare Full-Electric Bed **Requires Prior Authorization
$
Free
Size
Twin
Twin XL
Full
Queen
King
Bed Disposal
Yes
No
Memory Foam Mattress
Self-Adjusting Air/Foam Mattress with Optional Alternating Pressure Pump. **Requires Prior Auth (can be used on your existing bed or the full electric bed)
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Half Bedside Rails
$
Free
**Low Air Loss Therapy Bed
**Requires Prior Authorization
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
**Trapeze Bar - Freestanding or Mounted
**Requires Prior Authorization
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Type
Freestanding
Mounted
**Bed Side Table
**Requires Prior Authorization
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Transfer Bench with Glide Rail
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Bed Assist Bar with Storage Pocket
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Step-2-Bed Rail
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Adjustable Bed Assist Rail
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Gripper Socks
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Pain Management
Compression Gloves
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Size
S
M
L
XL
Aqua Cold and Hot Water Therapy System
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Bathroom Safety
Shower Chair
Removable back and arms
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Bedside Toilet
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Free Standing Toilet Rails
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Raised Toilet Seat with Removable Arms
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Permanent Grab Bar
Include Mounting Hardware
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Length
12"
16"
24"
30"
32"
36"
42"
48"
Clamp on Tub Rail
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Shower Grab Bar (Suction)
More than 3 grab bars requires a script. This total includes Suctionand Screw in bars.
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Length
12"
16"
Transfer Bench without Glide Rail
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Transfer Bench with Glide Rail
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Shower Stool
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Gripper Socks
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Gait Belt with Handles
*requires prior authorization
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Standard Gait Belt
*requires prior authorization
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Nutritional Supplements
Kangaroo Pump
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Jevity Tube Formula
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Diabetic Supplies
Continuous Glucose Monitor
*requires prior authorization
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Lancets (box of 100)
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Blood Glucose Test Strips
$
Free
Continuous Glucose Monitor Sensors
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Standard Glucose Monitor
*requires prior authorization
$
Free
Blood Glucose Control Solution
$
Free
**Other (NOTE: ALL dme items REQUIRE A SCRIPT/DEMOS/NOTES-notes must clearly show discussion between patient and physician for items requested per DOL requirements)
*PT MUST HAVE FACE-TO-FACE WITHIN LAST 90 DAYS-please ensure the patient's contact information so we can call and/or ship requested items. THANKS. ATI MEDICAL
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Patient Records (Facesheet, Notes, Order)
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