1.866.429.3188


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.