TennCare Diaper Request Form & Tiny steps supply

TennCare Diaper Request Form
TennCare insurance has authorized pharmacies to dispense 200 diapers per 2 months for members up to 2 years of age at no cost to the member.
Child's Full name:

First NameLast Name
Date of birth:

MonthDayYear
Date
Gender:
OptumRx ID# or SSN:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone number (cell):
Format: (000) 000-0000.
Preferred contact method
Cell TXT or Call
Child's medication allergies or other allergies:
Child's Primary Care Provider
If you do not get your Rx's at Baileyton Drug Company, do you authorize us to transfer:
Child's:
Rx Names or Numbers
Current Pharmacy:
Location:
Name of someone else?
Rx Names or Numbers
Current Pharmacy:
Location:
Please let us know if you want any more people transferred to our store, and we can get their information.
Mothers Full name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address
Zip code
OptumRx ID# or SS#
Diaper size requested:
Brand Request (subject to availability)
Childs Weight (Lbs)
I have requested the pharmacy to provide the above listed diapers/training pants and attest to the following: The diapers/training pants requested are for personal use for the indicated member. I agree not to resale the diapers/training pants provided under this covered benefit. I agree that once the pharmacy dispenses these diapers to me, they are no longer eligible for return or exchange at this pharmacy or at any other retailer.I understand that a change in diaper style or size cannot be requested until the next refill. I understand that this covered benefit is a diaper supplement and not intended to provide all the diapers members will require.
TO BE SIGNED BY PARENT OR GUARDIAN UPON ARRIVAL AT Baileyton Drug Company
Baileyton Drug Company offers the "Tiny Steps Supply Program" to provide children under 2 years

old with common over-the-counter medications at no cost to the parent or guardian.
These questions will be reviewed by a pharmacist and discussed with the parent or guardian at the pick up
appointment.
The parent or guardian may request these medications once every 30 days, and they will not be filled more frequently.
Providing these OTC medications is not intended to replace a consultation or visit with a medical provider. These medications
are readily available to the patient, but through this program we are able to provide additional counseling and expertise.
Please respond with YES or NO to each:
1. If covered by insurance, would you like an OTC medicine used for allergies liquid, eye(s) or nasal congestion?
Can Pick all three
2. If covered by insurance, would you like an OTC ointment used for minor cuts?

3. If covered by insurance,recommended by your pediatric provider would you like a liquid multivitamin? (ONLY 1)

Rows	Multivitamin Drops	Multivitamin Drops with IRON	Vitamin D Drops
1

4. If covered by insurance, would you like an electrolyte rehydration drink, if so what flavor?
Unflavored or Mixed Fruit
5. If covered by insurance, would you like anti-gas drops?
6. If covered by insurance, would you like a compounded medicated diaper rash cream?
7. If covered by insurance, would you like ONE of the following? (Only 1)
Tylenol Liquid, Suppositories, Motrin Liquid
PLEASE return form to 423-528-4258 via text, or to 423-528-4273 via fax or via email to
baileytondrugco@gmail.com
PLEASE call or indicate what day and time you would like to pick up your supplies.
We will need 1 business day notice before 4PM to order and prepare the supplies.
We are open 9am to 6pm, closed Sat &Sun. Allow for 15 to 20 mins initially to speak with a
Pharmacist about the supplies and Program.
We will reach out to you when your supplies are ready or if we have questions.
Should be Empty: