Reorder Request Form

Reorder Supplies

* - Indicates a required field

Customer Number

This can be found on an Invoice or Order/Proof of Deliver

First Name*

Last Name*

Date of Birth*

Street Address*

Address 2

City*

State*

Zip*

Phone Number*

Email

Best way to reach you?*

Additional Info

Patient Status Questionnaire

Who is completing this form?* Patient Authorized Representative

Authorized Representative's Name*

Are you currently in a Hospital or Nursing Home?* Yes No

Have you ordered from another supplier since your last order?* Yes No

Has your insurance changed since your last order?* Yes No

Insurance Information
Primary Insurance Name*
Primary Contract Number*
Primary Group Number
Secondary Insurance Name
Secondary Contract Number
Secondary Group Number

Have you changed physicians since your last order?* Yes No

Physician Information
Physician's Name*
Physician's Phone Number

Product Information

Please select the products you would like to reorder. You can request a maximum of seven products per submission.

Select Product*
Part #/Description*
Product Numbers can be located in the Details tab when viewing products in our Catalog.
Ordering Quantity*
Quantity Remaining*
Please provide the amount you have left
Unit of Measure
30 or 90 Day Supply Order 30 Days 90 Days

Assignment of Benefits (AOB):

I acknowledge this transaction is subject to ThedaCare At Home’s Terms & Conditions. I acknowledge I may be financially responsible for the purchase. Unless otherwise indicated, I hereby assign to Provider all insurance benefits or payments to which I am entitled from whatever source, including Medicare Part B, if applicable for any services, equipment, or supplies furnished to me by Provider. My assignment of benefits is ongoing and continuous unless and until cancelled by me in writing to the insurer(s) providing coverage. I authorize any holder of medical or other information about me to release to ThedaCare At Home any information requested by them for treatment, payment, or healthcare operations. I permit a copy of this authorization to be used in place of the original. Your insurance claim will be filed. Please refer to your plan schedule of benefits for coverage information. You are responsible for payment on items that are applied to your deductible, co-pays, and ono-covered items. We will notify you of any amount due. Returns of products must be made within 30 days of purchase. There will be a $25.00 service charge for NSF checks.

Click here to view our Terms & Conditions/Patient Rights & Responsibilities/Medicare Supplier Standards.

I have read and agree to the Terms & Conditions/Patient Rights & Responsibilities/Medicare Supplier Standards.*

Reorder Request Form

Reorder Supplies

Patient Status Questionnaire

Insurance Information

Physician Information

Product Information

Assignment of Benefits (AOB):