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PrimeCare Waiver Supplies LLC
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ODP Waiver Supplies
CHC Waiver Supplies
FMS & Billing Info
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Request FMS Invoice
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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)
Initials / Primary
Participant Initials / State Case ID / MCI Number
*
Category
*
— Select Choice —
Specialized Supplies
Assistive Technology
Specialized Medical Equipment and Supplies
Primary Unit Type (UOM)
*
— Select Choice —
EA (Each) – For single individual items
LOT (Bundle) – For multiple different items/packages
Select “EA” for single items, or “LOT” if your request includes a diverse package of multiple different items.
Product Specifications / Item Description
Please list each requested item, along with its specific quantity and any size/color preferences.
Home Delivery Shipping Address
Please provide complete address including Street Address, Apt / Suite, City, State and Zip Code
Submit
