Click the links below to view or download the information your need.
Intake Forms |
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| Release of Information Form | Release of Information Form - Switching PAP suppliers |
| Intake Form | Intake Form |
| Notice of Privacy Practice | Notice of Privacy Practice |
Physician Order Forms |
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| 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. |
| 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. |
| 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 |
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| Home Replacement Therapy 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 Forms |
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| 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. |
