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**MEDICAID RECIPIENTS ONLY!**
If you are a Medicaid Recipient, the following items could be available to you at no charge.
Adult Underwear * Adult Diapers * Bladder Control Pads * Pant Liners * Belted Undergarments * Disposable Bed Pads * Medical Gloves * Children's Pullups
You must be on Medicaid and have your doctor’s approval. If you would like information on the products available, contact our office FREE at 1-866-429-3188 or you can print and mail this flyer to P.O. Box 340795 Beavercreek, Ohio 45434-0795 and one of our representatives will contact you or your caregiver.
We will send all necessary forms to your doctor and upon approval, ship these products discreetly to your front door.
Patient Name ____________________________________________________
Contact Name ____________________________________________________
Patient Address__________________________________________________
City_______________________ State________________Zip____________
Patient Phone #(_____)_____________________D.O.B.________________
SS#_________________________ Medicaid Number____________________
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Doctor Name______________________________________________________
Doctor Address______________________________________ Suite_______
City_______________________ State________________Zip____________
Doctor Phone # (______)________________________
Doctor Fax # (______)_________________________
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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 | 
