Forms Library

Click the red type to view or download the information your need.

Intake Forms Description
Release of Information Form Release of Information Form - Switching PAP suppliers
Intake Form Intake Form

 

Physician Order Forms Description
Breast Pump Required documentation for insurance to help pay for breast pump.
Cane/Crutch Required documentation for insurance to help pay for cane or crutch.
CPAP Machine Required documentation for insurance to help pay for PAP.
Diabetic Supplies Required documentation for insurance to help pay for diabetic supplies.
Hospital Bed  Required documentation for insurance to help pay for hospital bed.
Seat Lift Mechanism Required documentation for insurance to help pay for lift chair.
Mastectomy Required documentation for insurance to help pay for mastectomy supplies.
Nebulizer Required documentation for insurance to help pay for nebulizer.
Negative Pressure Wound Therapy Required documentation for insurance to help pay for NPWT.
Non-Invasive Ventilator — NIV/Trilogy Required documentation for insurance to help pay for non-invasive ventilator - NIV/Trilogy. 
Oxygen Required documentation for insurance to help pay for oxygen.
Patient Lift (Hoyer Lift) Required documentation for insurance to help pay for patient lift.
Roho Cushions Required documentation for insurance to help pay for roho cushion.
Support Surfaces/Systems Required documentation for insurance to help pay for Support Systems (Alternating Pressure Pump and Low Air Loss Mattress).
U-Step Walker Required documentation for insurance to help pay for U Step walker.
Walker Required documentation for insurance to help pay for walker.
Wheelchair Required documentation for insurance to help pay for wheelchair.

 

Hormone Replacement Therapy Patient Questionnaire Description
HRT Questionnaire Hormone Replacement Therapy Patient Questionnaire, which we ask that you complete thoroughly to the best of your knowledge. Upon completion, please return to Jayhawk Pharmacy Custom Prescription Center, 6730 SW 29th, Topeka, KS 66610. Fax: 785-228-9745. Call: 785-228-9740.

 

Medicare Description
Medicare DMEPOS Supplier Standards Medicare DMEPOS supplier must meet in order to obtain and retain billing privileges.
Medicare and Insurance Guide Important information about coverage.
Best of Topeka 2018

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