Client Supply Form

Friendly Reminder: Placing an order once monthly with all the supplies the patient will need for the next 30 days, will help reduce delays in supply deliveries. If you are unsure if someone has already ordered supplies for a client, you can check by going to the client profile > Documents > Medical Supplies > Client Supply Order.

Your hard work of reducing the number of orders placed per month for clients makes a real difference not only internally with our Ohioans team but with our clients as well. Thank you!

Care Type*

Home HealthHospicePrivate Pay

Client Name*

First NameLast Name

Date of Birth*

Date

Shipping Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Clinician Information
First Name* Last Name* Email Order Date*

Ordering Provider Information
First Name* Last Name*

  Office Location
Street Address      City   State
Phone Number

What Type of Supplies are being Ordered?*

Does the Client have a Latex allergy?*

YesNoUnknown

IMPORTANT FYI: Coloplast is our prefered Brand for Ostomy products. Depending on insurance, we may not be able to provide the exact item that is being requested if it is not a Coloplast product. Please use reference sheets to know what products are avaliable.

Ostomy- Does the Client need a Coloplast Care Kit ordered? (This can only be ordered once per patient)

YesNo

Type of Ostomy:*

ColostomyIleostomyUrostomy

Ostomy ICD-10 Codes*

Ostomy: One Piece Systems- Allowable Amount is 20 per Month

	Brand Requested	Size of Stoma	Reference #	# Pieces Needed	Notes
Flat
Soft Convex
Light Convex
Deep Convex
Convex Flip (Coloplast Brand Only)
Pediatric

Ostomy: Two-Piece Systems- Allowable Amount is 20 Barriers & 20 Pouches

	Brand Requested	Size of Stoma	Reference #	# Pieces Needed	Notes
Flat Barrier
Soft Convex Barrier
Light Convex Barrier
Flat Click barrier
Light Convex Click Barrier
Deep Convex Click Barrier
Convex Flip Click Barrier
Drainable Pouch
High Output Pouch
Urostomy Pouch
Closed Pouch Allowable is 60
Pediatric Barrier
Pediatric Pouch

Ostomy Accessories

	Size of Stoma	Reference #	# Pieces Needed	Notes
Brava Thin Protective Seal 20 per month
Brava Thick Protective Seal 20 per month
Brava Convex Protective Seal 20 per month
Brava Strip Paste- 26555 20 per month
Brava Paste- 12050 2 per month
Brava Skin Barrier Wipes 20 per month
Brava Adhesive Remover 20 per month
Brava Elastic Barrier Strips 20 per month
Brava Protective Sheet 4x4 20 per month
Brava Powder- 19075 2 per month
Brava Lubricating Deodorant 20 per month
Brava Urostomy Night Bag 2 per month
Ostomy Belt 1 per month
Ostomy Scissors- 979131 1 every 6 months

If we are unable to get the exact Ref # requested for Clients Ostomy Products what option would be best for the patient:*

Order a similar product in a different brandOrder a different product in the same brandDo not place order and contact the Case Manager with options that are available

Urology: Select the Diagnosis to cover the Urology Supplies*

R33.9- Retention of urine, unspecifiedN31.9- Neuromuscular Dysfunction of bladder, unspecifiedF98.0- Enuresis not due to a substance of known physiological condition

Urology: Does the client have a UTI history (at least 2 within the last 12 months)

YesNoUnsure

Urology Supplies

	Size/ French Size	# of Changes per Month	Reference Number	# of Pieces Needed	# of Months Ordering for? (some insurance will only allow 1 month at a time)	Notes
Standard Tip 2 Way Foley 1 per month
Coude Tip 2 Way Foley 1 per month
Insertion Kit 1 per month
Intermittent Catheter, universal 200 per month
Intermittent Catheter, Female (Short) 200 per month
Lubrication Packets 200 per month
Condom Catheter 35 per month
Bedside Drainage Bag- 2,000mL 2 per month
Bedside Drainage Bag- 4,000mL 2 per month
Leg Drainage Bag- 1,000mL 2 per month
Leg Drainage Bag- 600mL 2 per month
Leg Strap 1 per month
Cath Stabilization Device 12 per month
Piston Syringe
Paper Tape 1" 1 roll every 2 months

Wound Care Information *

	ICD-10 Code or Description	Wound Thickness Or Stage	Location	Wound Size (LxWxD)	Drainage Amount	Type of Debridement
Wound 1
Wound 2
Wound 3
Wound 4
Wound 5
Wound 6
Wound 7
Wound 8

Wound Vac: Are you ordering Wound Vac Supplies?

YesNo

Wound Vac: Brand of Wound Vac

3M KCICorkMedelaGenadyne

KCI Wound Vac Supplies- Monthly Allowable- 3 cases of dressing & 2 cases of canisters

	Size	# Cases needed	How many does client have on hand?	Notes
Grandufoam with Dermatac Dressing Kit
Grandufoam with Regular Drape Dressing Kit
Simplace Dressing Kit
Bridge Dressing Kit
Peel & Place Dressing
White Foam
Canisters
Regular Drape
Dermatac Drape
Y Connector

Other Wound Vac Supplies- Monthly Allowable- 3 cases of dressing & 2 cases of canisters

	Size	# Cases Needed	How many does client have on hand?	Notes
Black Foam
White Foam
Drape
Canisters
Please add Phone number of Supplier in Notes section

Wound: Basic Dressings - Allowable amounts are for a 30 day period

	Size	Ref #	# of Pieces Needed	Freq of Change	# of Wounds Using this Dressing	Notes
ABD Pads 30 per wound
Bordered Gauze (Island Dressing) 30 per wound
Conforming Bandage 30 per wound
Gloves Not typically covered
Hydrogel (N-M Drainage) 3oz per wound
Iodoform Packing Strip
Paper Tape
Plain Packing Strip
Plastic Tape
Non-adherent Pads (Telfa)
Non-Woven Gauze 90 per wound
Normal Saline Not typically covered
Roll Gauze 30 per wound
Retention Cloth Tape
Triad Cream
Woven Gauze 90 per wound

Wound: Advance Dressings - Allowable amounts are for a 30 day period

	With Silver?	Size	Ref #	# of Pieces Needed	Freq of Change	# of Wounds Using this Dressing	Notes
Bordered Foam Sacral (M-H Drainage) 12 per wound
Bordered Foam Square (M-H Drainage) 12 per wound
Calcium Alginate (M-H Drainage) 30 per wound
Collagen Dressing (N-M Drainage)
Collagen Powder (N-M Drainage)
Gelling Fiber Dressing (M-H Drainage) 30 per wound
Hydrocolloid Dressing (L-M Drainage) 12 per wound
Hydrofera/Derma Blue Classic (M-H Drainage) 12 per wound
Hydrofera/Derma Blue Ready (M-H Drainage) 12 per wound
Hydrofera/Derma Blue Transfer (M-H Drainage) 12 per wound
Non-Bordered Adhesive Foam (M-H Drainage) 12 per wound
Non-Bordered, Non-Adhesive Foam (M-H Drainage) 12 per wound
Oil emulsion 30 per wound
Super Absorbent Dressing w/ Border (M-H Drainage) 15 per wound
Super Absorbent Dressing w/o Border (M-H Drainage) 30 per wound
Transparent Dressing (N-L Drainage) 12 per wound
Wound Contact Layer 4 per month
Xeroform 30 per wound

Wound: Compression - Allowable amounts are per extremity

	For Lymphedema?	Amount of Compression	# Pieces Needed	Notes
Unna Boots w/o Calamine 4 per month
Unna Boots w/ Calamine 4 per month
4" Coban 4 per month
6" Coban 4 per month
4" Ace Bandage 4 per month
6" Ace Bandage 4 per month
Tubigrip 4yds per month
Urgo K2 - 2 Layer Compression Kit 4 per month
Other 2-Layer Compression Kit 4 per month
3- Layer Compression Kit 4 per month
4-Layer Compression Kit 4 per month
Juxtalite Wraps 1 every 6 months

Juxtalite Wraps Measurements - Please put measurement in centimeters

	Left Leg	Right Leg
Ankle Circumference
Calf Circumference
Length (back of knee to bottom of heel)

Tracheostomy ICD-10 Codes*

C32.9- Unspecified Malignant neoplasm of larynxJ95.00- Unspecified tracheostomy complicationJ95.01- Hemorrhage from tracheostomy stomaJ95.02- Infection of tracheostomy stomaJ95.03- Malfunction of tracheostomy stomaJ95.04- Tracheo-esophageal fistula following tracheostomyJ95.09- Other tracheostomy complicationZ43.0- Encounter for attention for tracheostomyZ93.0- Tracheostomy status

Tracheostomy Care Supplies

	Size	# Pieces Needed	Ref #	Notes
Trach Tube Collar/Holder 30 per month
Trach Care Kit 30 per month
Inner Cannula 60 per month
Trach Suction Kit 60 per month
HME
Trach Mask
Split Gauze

Nephrostomy: Single or Bilateral*

Nephrostomy Supplies

	Ref #	# of Pieces Needed	Notes
10mL Saline Flush
Drainage Bag 2 per month
Transparent Dressing 4X4
Transparent Dressing 6X8
Split 4X4 Gauze
Split 2X2 Gauze
Iodine Swab
Tape 1" 1 roll every 2 months

Pleural Drain: Brand*

PleurXAspiraASEPT

Pleural Drain: Single or Bilateral?*

Pleural Drain ICD-10 Codes*

Pleural Drain Bottle Size*

Pleural Drain Frequency *

Pleural Drain Notes*

Other Supplies- This is not guaranteed to be ordered if it is not a coverable item or if it is not available on our formulary

	Item	Size	What is this for?	Freq of Change	Ref #	Notes
Item 1
Item 2
Item 3
Item 4
Item 5

If patient has multiple ordering providers for supplies, please list them below:

Client Supply Form

Client Information