[PDF] Byram Healthcare Medical Supply Order Form Phone

39695_7order_guide.pdf

Form Last Updated: December 5, 2018 Byram Healthcare, Inc., Worcester, MA Phone: (800) 248-4546 Fax: (888) 233-1799

Byram Healthcare

Medical Supply Order Form

Phone #: 1-800-248-4546 Fax #: 1-888-233-1799

REQUIRED PATIENT INFORMATION

Name:_________________________________________________M/F_________ Address:______________________________________Apt/Flr________________ City/State/Zip:_______________________________________________________ Patient͛s Phone: (_____)________________ DOB:________/________/________ Name of Care Manager:______________________________

Telephone # :______________________________

DO YOU WANT PT ORDER ON AUTOSHIP? ___________________________ Required information for any order direct billed to the patient͛s insurance

Dr.___________________________ Dr.͛s Phone͗ (ͺͺͺͺͺ)ͺͺͺͺͺͺͺͺͺ

Dr. NPI #_________________________

DX for Supplies:________________________________________________________ Tufts Senior Care Options ID #________________________________ ***Is this member currently on Hospice? ___________ If Yes, we can only supply Incontinent supplies, all other supplies must be obtained from Hospice provider. Product # Par Qty Incontinence Supplies Product # Par Qty DME Supplies Continued FQPV011 14 Adult Brief Small 20"-31" Mod Absorb (16ͬpk) AT32 1 Easy Reacher 32"

FQNU01*1 * Adult Brief M/L/XL /Light/Mod Absorb Nu-fit CDRLA8BL 1 Rollator Walker, W/Seat, Hand Break, Basket300lbs

FQPFNG01* * Adult Brief M/L/XL Heavy Absorb Perfit 360 IV6271 1 Wheels 5" Fidžed wͬGlide Caps(pr) for Walker

FQPVBNG01* * Adult Brief M/L/XL Ultim Absorb/Breezers (up to 70") MC04645001 1 BP Monitor Digital/Automatic W/Batteries

FQPV511 10 Adult Pull Up Small 20"-34" Extra Absorb (22/pk) MC04810001 1 BP Monitor Digital Wrist Style

FQNU51* 4 Adult Pull Up M/L/XL 32"-44" Light Absorb (50/pk) MC04655001 1 BP Monitor Digital W/Large cuff

FQPV51* * Adult Pull Up M/L/XL Extra Plus Absorb / unisex IVPB2057* 1 Cane 31"-42" W/STRAP FQPVS512 12 Adult Pull Up S/M Max Absorb (18/pk) / unisex IVPB3057 1 Small Base Quad Cane FQPVS51* * Adult Pull Up L/XL Max Absorb / unisex CDPB2055K 1 Folding Cane Adjustable

FQPV517 19 Adult Pull Up yyL 68"-80" Edžtra Absorb (12/pk)/uni CDWKAAN2B 1 Folding Walker: Adult Junior

FQPFW51* * Adult Pull Up for Women M/LG/XL Mod Absorb IV9630 1 Commode 3 In 1 FQPFM51* * Adult Pull Up for Men M/LG/XL Mod Absorb CDBSB24C 1 Commode Bariatric Up To 400LB

FQPWC51*1 * Adult Pull Up for Women S/M L/XL Max Absorb SQ324802 1 Aloe Vesta Daily Moisturizer 2 oz.

FQPUM51*1 * Adult Pull Up for Men S/M & L/XL Max Absorb CT0406 1 Sween Moisturizing Lotion 4 oz. FQPV926 8 Bladder control Pad 7.25" Very Light (26ͬpk) Product # Par Qty Urology Supplies

FQPV930 7 Bladder control Pad 9.25" Long Light (30ͬpk) BD802030 31 Foley Catheter Insertion Tray 30ml (1/kt)

FQBC012 11 Bladder Control Pad 9.25" Mod Absorb (20ͬpk) BD802010 31 Foley Catheter Insertion Tray 10ml (1/kt)

FQBC013 14 Bladder Control Pad 11" Mod Absorb (16ͬpk) BD802001 3 Bedside Drainage Bag 2000ml (1/ea)

FQPV9161 4 Bladder Control Pad 11" Madž Absorb (48ͬpk) SQ37449 12 Flexitrack, anchoring device, (1/ea)

FQPV9151 5 Bladder Control Pads 13" Madž Absorb(39ͬpk) BD1235** 31 Foley Cath, Silicone Coated: ______FR 5CC

FQPV9231 6 Bladder Control Pads 16" Ultimate Absorb (33ͬpk) BD1236** 31 Foley Cath, Silicone Coated: ______FR 30CC

FQPL1001 4 Pant Liners Small 6"dž13.5" Light Absorb (52ͬpk) BD802060 4 Irrigation Tray with Piston Syringe (1/kt)

FQPL1131 12 Pant Liners Large Plus 13"dž28" (16ͬpk) MDDYND125* 3 Leg Bag, Med 19oz (1/ea)

FQCRF150 1 cs Underpad Mod Absorb 21"dž34" (50ͬpk) MDDYND125* 3 Leg Bag, Large 32oz (1/ea)

FQUP425 9 Underpad Super Absorb 30"dž36" (25ͬpk) MDDYND168* 1 Leg Strap - Velcro (1/ea)

SA1974 2 Underpad Reusable 32"dž36" MT8*** 250 External/Condom Catheter: SM Med Lg XL

SA1997 2 Underpad Reusable 36"dž54" wͬTuck-In Flaps BD4A4194 3 Edžtension Tubing 18" NS Latedž Free

SA1999 1 Underpads Reusable 36"dž72" DY1250 250 Lubricating Jelly 2.7gr Sterile Packet DY1314 1 Washcloths Wipes (46 pk) DY1254 4 Lubricating Jelly 4oz Sterile Tube

FQWW902 1 Washcloths Wipes (96 pk) NO OVERAGES BD802214 250 Urethral Cath Tray w/14fr Vinyl Cath , BZK Wipes

HYH5503* 4 Gloves vinyl S / M / L / XL BD772100 31 Urethral Cath Tray w/o Cath , BZK Wipes Product # Par Qty DME Supplies MT240 250 Female Intermittent Cath 14fr 6"

CDPBBSTB 1 Transfer Bench Non-Padded w/back (400 lbs) CUM1* 250 Intermittent Catheter 16" ͺͺͺͺfr Latedž Free

CA11825 1 Bath Mat 32" dž 16" Non-Slip w/Suction Cups BD8024* 250 Catheter, Intermittent, Red Rubber _______fr

CDB20400 1 Bathtub Rail White 13.5"X 7"X 1" CUCS** 250 Interm. Cath Θ Bag Kit 16"ͺͺͺͺͺͺͺfr Latedž Free

D*1912 1 Grab Bar 12" Suction Cup Product # Qty Incontinence Samples

D*1916 1 Grab Bar 16" Suction Cup FQCRB01*SA ** Adult Brief Procare Sample(2/pk): Med LG XL

CDB20900 1 Grab Bar 12" Chrome Knurled Grip (Screws in) FQPV51*SA ** Adult Pull UP Sample Extra(2/pk): Med LG XL

CDB21000 1 Grab Bar 16" Chrome Grip Knurled (Screws in) FQNU51*SA ** Adult Pull UP Sample Mod(2/pk): Med LG XL

DMT1583 1 Hand Held Shower FQBC01*SA ** Bladder Control Pad Samples(2/pk): Reg Lg CDP56600 1 Bed Support Rail (Fits Most Bed Sizes) (250 lbs) Product # Qty Nutrition Supplies

CDP56900 1 Bed Rail 300LB Weight Capacity Easy-Up RL* Ensure Chocolate Vanilla Strawberry (Plus)

HLM100LB 1 Floor Scale Dial 270LB RL* Ensure Clear Apple Mixed Berry

HLM800KL 1 Floor Scale Digital 390 LBS Low Profile RL* Glucerna Chocolate Vanilla Strawberry

IV9781 1 Bath Chair W/Back, Adjustable Legs (400 lbs) NE* Boost Chocolate Vanilla Strawberry (Plus)

IV9780 1 Bath Chair No Back, Adjustable Legs (400 lbs) Product # Par Qty Diabetic Supplies IV1301RTS 1 Raised Toilet Seat No Arms, Clamp-On LS023194 N/A Verio Flex Glucometer IV1302RTS 1 Raised Toilet Seat W/Arms, Clamp-On LS022978 N/A Verio Test Strips (50/box) DMT5076 1 Urinal Male Plastic W/Cover LS022136 N/A Lancets 100/box CDB35800 1 Toilet Safety Frame DY1114 N/A Alcohol Prep Pads (100 per box)

Pill Boxes Are To Be Obtained at SCO Office!

#9884 Tufts Senior Care Options Plan

Referral # 201812