TennCare Diaper Request Form

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
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Contact

First NameLast Name
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.
Is the mother interested in prenatal vitamins? (This can be before delivery/ 2 years after)
Mothers Full Name

First NameLast Name
Mothers Date of Birth

MonthDayYear
Date
OptumRx ID# or SSN
Mothers Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
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:
If covered by insurance, would you like an OTC medicine used for allergies liquid, eye(s) or nasal congestion?
If covered by insurance, would you like an OTC ointment used for minor cuts? (ONLY 1)
If covered by insurance, recommended by your pediatric provider would you like a liquid multivitamin? (ONLY 1)
If covered by insurance, would you like an electrolyte rehydration drink, if so what flavor? (Flavors: unflavored and mixed fruit)
If covered by insurance, would you like anti-gas drops?
If covered by insurance, would you like a compounded medicated diaper rash cream?
If covered by insurance, would you like one of the following? (PICK ONE)Please indicate Tylenol liquid or suppositories OR Motrin liquid
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:

TennCare Diaper Request Form

If you do not get your Rx’s at Baileyton Drug Company, do you authorize us to transfer:

Please let us know if you want any more people transferred to our store, and we can get their information.

Please respond with YES or NO to each: