• TennCare Diaper and Tiny Steps Supply 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.
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Does the child have any medication allergies or other allergies?*
  • Diaper Brand Requested (subject to availability)*

  • I have requested the pharmacy to provide the above listed diapers and attest to the following: The diapers requested are for personal use for the indicated member. I agree not to resale the diapers 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.

  • The following questions refer to the mother:

  • Is the mother interested in prenatal vitamins? This can be before delivery and up to 2 years after. Prenatal vitamins might have a small copay typically ranging from $0 to $3. If yes, please select your preference of prenatal vitamins. If not interested, please select not interested.*

  • If the mother is interested in prenatal vitamins, please fill in the following sections:

  • Mother's Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Does the mother have any medication allergies or other allergies?
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Preferred Method of Contact: Please select if you would like us to contact you via phone call or text message.*

  • 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 pickup 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.

  • If covered by insurance, would you like an OTC medicine used for allergies*
  • If covered by insurance, would you like an OTC ointment used for minor cuts?*
  • If covered by insurance and recommended by a provider, would you like anappropriate liquid vitamin? We are unable to dispense vitamins without your pediatrician’s recommendation. Not every infant and child needs a vitamin, so it is for the safety of your child. If yes, please select which vitamin your child’s pediatrician recommend they take. If not applicable, please select “vitamin has not been recommended by child’s pediatrician or I am not interested”.*
  • If covered by insurance, would you like a bottle of Pedialyte, if so what flavor?*
  • If covered by insurance, would you like anti-gas drops?*
  • If covered by insurance, would you like a medicated diaper rash cream? If yes, please select which diaper rash cream you would like to request. If you are not interested, please select not interested.*
  • If covered by insurance, would you like an OTC medicine for pain or fever? If yes, please select one of the following medications. If you are not interested, please select not interested.*

  • We will need 1 business day notice before 4PM to order and prepare the supplies. We are open 9AM to 6PM Monday through Friday (closed Sat & Sun). Allow for 15-20 minutes 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.

  • If you do not get your prescription medicine from Baileyton Drug Company, do you authorize us to transfer your prescriptions from your current pharmacy to Baileyton Drug Company?

  • If yes, we will contact you about transferring.

  • Should be Empty: