PrimeCare Waiver Supplies LLC

Coordinator/Caregiver Full Name

Agency / SCO Name

E-mail Address

Primary Contact Phone Number

Participant Age Group / Waiver Classification

Under 60 (ODP / Adult Autism Waiver)
60+ Senior (Community Health Choice Waiver)

Designated Fiscal Management Service (FMS)

Tempus Unlimited
Palco
Public Partnership (PPL)

Participant Initials / State Case ID / MCI Number

Category

Specific Product Description / Care Plan Requirements

Type the exact item details, measurements, product link or custom behavioral / safety equipments that participant requires

Item Quantity

Unit Type (UOM)

Number Plan Participant

Home Delivery Shipping Address

Please provide complete address including Street Address, Apt / Suite, City, State and Zip Code