TriStar Medical Services, LLC

Request for Incontinence Products




Patient Name___________________________________________________ Contact Name___________________________________________________ Patient Address_______________________________________________ City_______________________ State________________ Zip_____________ Patient Phone #(_____)_____________________D.O.B.________________ SS#_________________________ Medicaid Number_________________

=================================================================



Doctor Name____________________________________________________ Doctor Address______________________________________ Suite_______ City_______________________ State________________Zip______________ Doctor Phone # (______)___________________________
Doctor Fax # (______)_________________________

=================================================================


Phone: 937-429-3188
Toll Free: 1-866-429-3188
Fax: 937-429-3144
E-Mail: TriStar4u@sbcglobal.net
P.O. Box 340795 • Beavercreek, Ohio 45434-0795
Web Address: www.tristar-incontinence-products.com
TMS-0802-01




If you are a Medicaid Recipient, the following items may be available to you at no charge.


Adult Underwear * Adult Diapers * Bladder Control Pads * Pant Liners * Belted Undergarments * Disposable Bed Pads * Children's Diapers


Print this page, complete the form and mail to:


TriStar Medical Services, LLC
P.O. Box 340795
Beavercreek, OH 45434


You can also fax the form to our office at 937-429-3144.