• Client Supply Request Form

  • Care Type*

  • Friendly Reminder: Please request only the amount of supplies needed for up to two weeks. Requests exceeding a two-week supply will not be approved.

  • Client Information

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Clinician Information
    *   *        Pick a Date   

  • Are supplies being ordered at a SOC or ROC Visit?*
  • What Type of Supplies are being Ordered?*
  • Does the Client have a Latex allergy?*

  • If the patient is currently receiving tube feed by a pharmacy, the patient should request bags, flushes, dressing supplies, ect from the pharmacy. 

  • How often are the tube/drain sites having their dressings changed?*
  • Tube/Drain Supplies Needed*
  • What size of Drain/Split Gauze is needed?*
  • What size of Paper tape is needed?*
  • What size of Transparent dressing is needed?*

  • 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)*
  • Type of Ostomy:*
  • Ostomy ICD-10 Codes*
  • Colostomy- The patient wears a:*
  • Ileostomy- The patient wears a:*
  • Urostomy- The patient wears a:*
  • Does the patient need any of the following accessories?*
  • Protective Seal/Moldable Ring- 20 per month per ostomy*
  • Coloplast Thin Protective Seal/Ring*
  • Coloplast Thick Protective Seal/Ring*
  • Coloplast Convex Protective Seal/Ring*
  • Hollister Ostomy Rings*
  • ConvaTec Ostomy Rings*
  • Barrier Strips or Protective Sheets? (These typically cannot be ordered together for the same ostomy)*
  • Ostomy Paste*
  • Adhesive Remover*
  • Skin Barrier*
  • Lubricating Deodorant*
  • Ostomy Belt - Only 1 will be ordered per month per ostomy*
  • Urostomy Night Bag*
  • High Output Bedside Drainage bag for fecal output*
  • If we are unable to get the exact Ref # requested for Clients Ostomy Products what option would be best for the patient:*
  • Urology: Select the Diagnosis to cover the Urology Supplies*
  • Urology: Does the client have a UTI history (at least 2 within the last 12 months)*
  • French Size Needed*
  • Coude or Straight Tip?*
  • Foley Balloon Size*
  • Foley Material*
  • Intermittent: Type of Intermittent Catheter*
  • Intermittent: Length of Catheter*
  • Type of Condom Catheter*
  • Urology Accessories*
  • What size Bedside Drainage Bag?*
  • What size Leg Drainage Bag?*
  • Type of Drainage Port for Bedside Drainage Bag*
  • Type of Drainage Port for Leg Drainage Bag*
  • Type of Leg Strap - Allowable Amount: 1 per month*

  • 1 roll of tape will be ordered per the number of months we are ordering for. Example: If we are ordering for 2 months, 2 rolls of tape will be requested for the patient. 

  • What size of Lubrication is needed? Only allowed when uncoated Intermittent catheters are ordered.*
  • What tape is needed?*

  • 1 roll of tape will be ordered per the number of months we are ordering for. Example: If we are ordering for 2 months, 2 rolls of tape will be requested for the patient. 

  • What size of Split/Drain gauze is needed?*
  • When was the last wound measurement entered in Wound Assessment form? Must be within the last 14 days or supplies will not be ordered. *
     - -
    2 digit month, 2 digit day, 4 digit year
  • Have all wounds been debrided or surgically created? If wound has not been debrided or Surgically created, wound supplies may not be covered by insurance.*
  • What type of debridement have the wound(s) had:*
  • KCI Items*
  • Other Wound Vacs*
  • Format: (000) 000-0000.
  • Size of Black Foam*
  • Size of White Foam*

  • IMPORTANT NOTICE: 

    Nurses are responsible for maintaining adequate trunk stock of routine medical supplies for use during visits. Supplies used to cleanse wounds are not covered by insurance.

    During nursing visits, wound cleansing should be completed using trunk stock supplies. Gauze, saline, or other items ordered solely for wound cleansing outside of a nursing visit will not be supplied and may require the patient to pay out of pocket.

    If you have any questions, please contact your Clinical Leader, DON, or Ancillary Team.

    Thank you!

  • Wound Cleansers- All of these are private pay & are NOT covered by insurance. The patient will be reached out to purchase these items out of pocket if selected*
  • Gels & Creams*
  • What size of Hydrogel bottle is needed?*
  • Triad Paste tube size*
  • Honey gel/paste bottle size*
  • Basic Dressings- Gauze: These are not to be used for cleaning the wound. Gauze for nurse to cleanse the wound(s) should come from trunk stock supplies.*
  • What Size of ABD pad are needed?*
  • What Gauze are needed?*
  • What size of Bordered Gauze are needed?*
  • What size of Roll Gauze are needed?*
  • What size of Conforming Bandage rolls are needed?*
  • What size of Non-Adherent pads are needed?*
  • Basic Dressings- Packing Strips/Dressings*
  • What Size of Plain Packing Strips are needed?*
  • What Size of Iodoform Packing Strips are needed?*
  • What Size of Mesalt are needed?*
  • Basic Dressings- Tape: Coverage amount is calculated by size of wound & frequency of change*
  • What size of Paper Tape is needed?*
  • What size of Plastic/Transparent Tape is needed?
  • What size of Cloth/Silk tape is needed?*
  • What Retention Tape is needed?*
  • Advance Wound Care Dressings*

  • Foam Dressing Coverage Guidelines

    Foam dressings are covered only when the wound is documented as Full Thickness, Stage 3, Stage 4, or Unstageable and has moderate or greater drainage.

    Foam dressings are not covered for padding, protection of non-qualifying wounds, or preventive use.

    For qualifying wounds, the allowable amount is up to 12 foam dressings per wound per month, unless a foam rope is being used as a wound filler.

    Only one type of foam dressing may be used per wound at a time. Multiple foam products cannot be used simultaneously.
    Example: If blue foam is used, it cannot also be covered with a bordered foam dressing.

    Ordering foam dressings for non-qualifying wounds will delay supplies. Please ensure documentation clearly supports qualification before placing the order.

    If the wound does not qualify, requires more frequent changes, or you need guidance on alternative products, please contact Ancillary before ordering.

  • Advance Dressings- Foams*
  • What type of Blue foam is needed?*
  • What size of Square Bordered foam is needed?*
  • What size of Sacral Bordered Foam Dressing is needed?*
  • What size of the IoPlex Foam Dressing are needed?*
  • What size of Non-Bordered Adhesive Foam is needed?*
  • What size of the Non-bordered, Non-Adhesive foam is needed?*
  • What size of Silver Foam is needed?*

  • Alginate, Gelling Fiber & Super Absorbent Dressing Guidelines

    Alginates, gelling fibers, and most super absorbent dressings are considered the same product category for coverage purposes.

    These dressings are covered only for wounds documented as Full Thickness, Stage 3, Stage 4, or Unstageable with moderate or greater drainage.

    Please ensure documentation clearly supports wound qualification before placing the order. Ordering for non-qualifying wounds will result in delays, as these items cannot be supplied.

    Allowable amount:
    Up to 30 dressings per wound every 30 days (equivalent to daily changes).

    Only one dressing from this category may be used per wound at a daily frequency. Ordering two products from this category for the same wound (e.g., calcium alginate plus a bordered super absorbent dressing for daily changes) will not be covered.

    If the wound does not qualify or requires more frequent changes than allowed, please contact the Ancillary team prior to ordering to discuss covered alternatives.

    Thank you.

  • Advance Dressings- Alginate, Gelling Fiber & Super Absorbent Dressings: Only covered for Moderate - Copious amount of drainage and Full Thickness wounds*
  • What size of Ca Alginate is needed?*
  • What size of Alginate Ag is needed?*
  • What size of Gelling Fiber is needed?*
  • What size of Gelling Fiber with Silver is needed?*
  • What size of Super Absorbent dressing without border is needed?*
  • What size of Qwick dressing is needed?*
  • What size of Super Absorbent dressing with adhesive bordered is needed?*
  • What size of UrgoClean Ag is needed? - This must be ordered by the provider by name. This cannot be ordered in place of Alginate or gelling fiber.*

  • Collagen dressings are covered for full-thickness wounds, including Stage 3, Stage 4, and unstageable wounds, with none to moderate drainage.

    Collagen is used to help stimulate healing in stalled wounds.

    Collagen dressings are not covered for wounds with heavy exudate, third-degree burns, or when active vasculitis is present.

    Collagen should be changed PRN (as needed) — only after the previous collagen dressing has fully dissolved in the wound.

  • Type of Collagen Dressing*
  • What size of Collagen Dressing is needed?*
  • What size of Collage with Silver Dressings are needed?
  • Advance Wound Dressings- Hydrocolloid Dressing: Covered for Full Thickness wounds with no to moderate drainage.*
  • What size of Hydrocolloid Dressing is needed?*
  • What size of Hydrocolloid Thin Dressing is needed?*
  • Advance Wound Dressings- Non-Adherent Dressings: Covered for None - Moderate Draining wounds with Partial or Full Thickness*
  • What size of Adaptic is needed?*
  • What size of Xeroform is needed?*

  • Wound contact layers are used to fully line the wound bed to prevent the secondary (overlaying) dressing from adhering to the wound.

    These dressings are not covered when used with non-adherent or semi-adherent dressings.

    Contact layers should not be changed with every dressing change. Coverage allows for replacement once per week only.

  • What size of Wound Contact Layer is needed?*
  • Specialty Dressings*
  • What size of Transparent dressing is needed?*
  • Compression & Wraps- Disposable wraps are typically only covered 1 per week per extremity. Patient may be contacted to pay OOP if frequency of change is greater than 1 per week.*
  • What Items for Unna Boots do you need? - This does not include coban, ace, or other coverings to go on top of the unna boot wrap*
  • What Layered Compression Kit(s) are needed?*
  • What size of Elastic Bandage is needed?*
  • What size of Coban is needed?*
  • Where does the Gradient Compression wrap need to cover?*
  • Lymphedema Diagnosis*
  • What extremity is needing compression items for Lymphedema*
  • Has the patient received a gradient compression wrap within the last 6 months for the extremity/extremities you are requesting?*
  • What Compression Wrap is needed?*
  • Tracheostomy ICD-10 Codes*
  • Tracheostomy Care Supplies*
  • What size of split gauze are needed?*
  • What Nephrostomy/Biliary Supplies are needed?*
  • What size of Transparent dressing is needed?*
  • What size of split/drain gauze are needed?*
  • Pleural/Peritoneal Drain ICD-10 Codes*

  • I verified that:

    1. All requested supplies are listed on the patient’s current care plan.


    2. The care plan includes complete details for each supply requested, including frequency of change and any other required specifications.


    3. For wound care supplies, the wound assessment form has been completed with wound measurements, wound type, wound thickness/stage, and drainage amount within the last 14 days.

     

    I understand that if this statement is not confirmed, or if it is confirmed but the required documentation is not present in the chart, supplies may not be ordered and the Ancillary Team may request a new form to be submitted once all required orders and documentation are complete and available in the patient’s record.

     

  • Please Select an Option about above Statement:*
  • Is there a plan to D/C the patient from services within the next 30 days?*

  • FYI: Depending on Insurance, if the patient is going to D/C within the next 30 days, a whole month of supplies may not be sent. 

  • What is the estimated date that the patient will be D/C from services? *
     - -
    2 digit month, 2 digit day, 4 digit year
  • Does the patient need set up with a Medical Supplier once they are D/C?*
  • Other Supplies- Adding Items to this table will cause the supply order to go through an approval process by the Ancillary Team Leader and/or Manager, which may cause delays with the order. Items on here are not guaranteed to be approved. The Ancillary Team will reach out via Teams if any of the items are unable to be ordered.
    Rows
  • Hospice- What Routine Supplies are being Ordered?*
  • Hospice- What Specialty Supplies are being Ordered?*
  • Hospice- What Incontinence Items are Needed?*
  • Hospice- What type of Chux Pads are needed?*
  • Hospice- What Hygiene Items are Needed?*

  • 15 Oral Swabs will be placed on this order

  • Hospice- What Skin Care & Basic Wound Care Items are needed?*
  • Hospice- What type of Barrier Cream is needed?*

  • 1 Box of 30 Skin Barrier wipes will be added to this order. 

  • 1 Box of Gloves for Caregiver/patient use will be ordered. 

  • Hospice- What Size of ABD pads are needed?*
  • Hospice- What size of Telfa pads are needed?*
  • Hospice- What size of Island Dressing are needed?*
  • Hospice- What Medication Supplies are Needed?*
  • Hospice- What Size of Oral Syringes is needed?*

  • FYI: We can only order 1 gait belt per patient and gait belts can only be sent when other supplies are also being ordered. If no other supplies are needed, please pick up a gait belt from the office. 

  • Hospice- Gait Belt Size*
  • Hospice- What Respiratory Items are needed?*
  • Hospice- What length of O2 Tubing is needed?*
  • Hospice- What type of Nebulizer Kit is needed?*
  • Hospice- What Urology Items are needed?*
  • Hospice- What French Size Foley is needed?*
  • Hospice- What size Balloon for Foley Catheter is needed?*
  • Hospice- What type of Foley Catheter is needed?*
  • Hospice - What size of Condom Catheter is needed?*

  • 1 Urinal Containter will be sent 

  • Hospice- Pleural Drain Supplies*
  • Hospice- How often is the patient draining?*
  • Hospice- Does the Patient have a singular drain or bilateral drains?*
  • Hospice- What Advance Wound Care Dressings are needed?*
  • Hospice- What size(s) of Bordered Foam are needed?*
  • Hospice- What size of Alginate Dressings are needed?*
  • Hospice- What size(s) of Optilocks are needed?*
  • Hospice- What size(s) of transparent dressings are needed?
  • Hospice- What size(s) of Coban is needed?*
  • Hospice- What Ostomy Products are needed?*

  • Coloplast is currently the only brand we are able to order for Ostomy products. We have a set formulary for what items we will order depending on what type of system is requested, size of the stoma and type of ostomy. 

    Only 1 box of each item will be purchased at a time for ostomy supplies, besides the belt which only 1 belt will be sent. 1 box of each of this items should be enough supplies for the patient for 2-4 weeks. 

  • Hospice- What Type of Tracheostomy Items are needed?*
  • Hospice- What Nephrostomy Items are needed?*

  • One Neph drainage bag will be sent per Neph tube for a 2 week period.

  • Hospice- How often are the Nephrostomy tube(s) being flushed?*
  • Hospice- How often are the Nephrostomy tube(s) dressings being changed?*
  • What Other Supplies are being Requested? Please note these supplies will have to go through an approval processes & can delay the order. The Ancillary Team will reach out if the Items Requested are not approved by Hospice Management.
    Rows
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