Order Request Form

Iowa Order Request Form

Please make sure to fill in the required fields and submit this form to complete your order.
Confirm Phone Number*
Email
example@example.com
Verify Shipping Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Doctors Information

We'll use this to contact your doctor and obtain your most recent prescription. We'll handle all of the paperwork so you don't have to!
Doctors Name*

First NameLast Name
Doctors Phone Number*

Who Is Your Insurance Provider*
Please List Your Insurance Provider
Iowa Medicaid Quantity Maximums - 90 Day Supply
Category A - Diapers(w/tabs) - max qty = 1,080 / 90 Days
Category B - Urinary Pad/Booster/Liner - max qty = 450 / 90 Days
Category C - Underwear/Pull-on - max qty = 450 / 90 Days
Category D - Disposable Bed Pads - max qty = 600 / 90 Days
Category E - Disposable Gloves & Sanitary Wipes (requires Prior Authorization)

Combinations of above.

A & B - Total Max Quantity = 1,080 i.e. 600 diapers w/tabs, 450 Urinary pads
B & C - Total Max Quantity = 450
A & C - Total Max 1,080 , Category C Max 450
A & B & C - Total Max 1,080 , Category B & C Combined Max 450
A & D - Total Max 1,260 , Category A Max 1,080 & Category D Max 180
B or C with D - Total Max 630 , Category B or C Max 450 & Category D Max 180

***Filling out the product form:***
1. Select the check box next to each item you wish to order. ALL products have been pre-selected for you.
2. For each product selected, please select the appropriate type, size, quantity and absorbency.
3. Products you do not want included on your order, please unselect the blue check box.
4. Click "SUBMIT" when completed.
Please Note: Gloves, wipes and bed pads must be selected with either pull ups, diapers with tabs or urinary pads.
Products (SELECT ALL THAT APPLY). Please select the appropriate type, size, quantity and absorbency. *
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Pull-UpsMaximum allowable is 450 pieces
$ Free TypeSizeQuantity



Diapers With TabsMaximum allowable is 1080 pieces
$ Free TypeSizeQuantity



Urinary Pads / Booster PadsMaximum allowable is 450 pieces
$ Free Pad SizeAbsorbencyQuantity



GlovesRequires Prior Authorization
$ Free SizeQuantity



Hygienic WipesRequires Prior Authorization
$ Free Quantity



Disposable Bed PadsMaximum allowable is 600 pieces
$ Free Quantity
Should be Empty:

Iowa Order Request Form

Doctors Information

Iowa Medicaid Quantity Maximums - 90 Day Supply