1. Private Pay Individual Individual Patient or Caregiver:
Incontinence Products
Referrals & Free Samples
Telephone
Office:
Toll Free:
Fax:
Office & Distribution Center Show Room & Customer Pickup Hours
4011 Millersville Road Monday through Friday: 9:00am to 5:00pm
Indianapolis, Indiana Closed Weekends and Holidays
MCE Member
Referral
To be completed by
Healthcare Provider:
Please fax Prescriptions (see below)
Contact information of patient or legal custodian if a minor or assigned:
Name___________________________
Phone___________________________
Medicaid #_______________________
Private Pay Individual
Free Samples
To be completed by
Individual Patient or Caregiver:
Please call with the following information
Name___________________________
Address _________________________
Phone___________________________
Attach Prescription here for MCE Referral
Please include the following:
Standard information – pt name, date, refills etc
ICD9 code
Words “Incontinence Products”
DKC In-Home Healthcare Supply Co.
Is an Indiana Hoosier Healthwise Provider