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Incontinence Products for Medicaid Recipients

Incontinence products....for Medicaid recipients! We currently provide products to qualified Illinois, Ohio and Pennsylvania Medicaid recipients. Our incontinent supplies may be available to you at no charge if you meet state requirements, have a medical condition and your doctor's approval. We will send all necessary forms to your doctor and upon approval, ship these products discreetly to your front door.

It's simple to get started.... complete the Medicaid Recipient Information form below and click the submit to TriStar button.

One of our friendly.... staff members will take care of the rest. You will be contacted to discuss what products you desire and best fit your needs. They will also gather the remaining required information at that time.

You may also.... contact our office toll free at 1-866-429-3188 and we'll be happy to take your information over the phone, mail you a form, or answer any additional questions you may have.

One additional option.... You may also print out one of our forms, fill in the required information and mail us the form. Click here to access form.



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Medicaid Recipient Information
Please note that all fields followed by an asterisk must be filled in.
First Name*
Last Name
E-mail Address
Street Address
City
State/Prov
Zip/Postal Code
Home Phone*
Comments here >>
Please have the following information available
Medicaid Number
Date of Birth
Social Security Number
Doctor's Name
Doctor's Adress
Doctor's Phone Number
Doctor's Fax Number
Doctor's NPI Number

Please enter the word that you see below.

  




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