Patient & Provider Order Form
Sign in / My Orders · How ordering works
Your PDF copy is emailed to you so you can forward it (email or fax) to the treating doctor, who adds the signature and date. Only the referring provider signs this order — an NPI-holding practitioner submitting on their own behalf signs here; everyone else leaves both blank. (When the doctor e-signs right after submitting, leave blank as well.)
Family or caregivers we can reach if the patient is unable to talk. This helps us process the order faster.
If your plan isn't listed — for example CountyCare or most United / UHC advantage plans — we may not be able to bill it. Please call (773) 205-6993 to check.
At least one of fax, email, or office phone is required. A case worker usually cannot get the doctor's cell — that's fine; the clinic fax, email, or phone works. An office phone alone may go through a phone tree and delay the signed prescription for days, so please add a fax or email whenever you can. (Not needed when the treating doctor signs electronically below — the signature is captured right away.)
Add your email and/or phone in the first step — each choice appears once we can actually reach you there.
Your personal mobile number will NOT be saved in our system database.
Search by keyword or code and add one or more diagnoses. For DME, payers want ICD-10-CM codes on the documentation.
Search our catalog to add items, or type a custom item below. Standard quantities are filled in for incontinence supplies (Pull ups/Diapers 200, Liners 120, Underpads 150, Gloves 200).
Refills: — 11 = a 12-month supply for incontinence before annual re-authorization · 99 = as long as needed (equipment)
Have the doctor's prescription? Upload it here to speed things up — along with the insurance card, face sheet, or any other documents.
PDF, JPG, PNG, or Word. Up to 6 files, 10 MB each.
This starts your order. To complete it, we'll also need a diagnosis and documentation from the patient's doctor. If you already have the prescription, you can attach it above — otherwise our team will coordinate that after you submit.
Questions? Call (773) 205-6993. Your information is transmitted securely. Advanced Medical Supply, Inc. — newmedsupplies.com
We've dispatched a 6-digit confirmation security token text via Twilio directly to your provider phone number. Enter it below to unlock the DWO signature workflow room.