Ready to reorder incontinence products? Covered by Illinois Medicaid!

Products to Order*
- Select All
- Pull-on Underwear
- Briefs (with tabs)
- Liners/pads
Name*
First Last
Address*
Street Address City State ZIP Code
Phone*
Email*
Medicaid Insurance Type*
Medicaid Insurance ID*
Waist Size (inches)*
Consent to Purchase*
I agree to the privacy policy.
By checking this box, I understand that I am authorizing Neb Medical Services to supply me with Incontinence Products and I authorize Neb Medical Services to bill my insurance on my behalf. I understand that I will be responsible for insurance cost sharing and I understand that opened/used equipment cannot be returned due to infection control purposes.
Date of Consent*
MM slash DD slash YYYY
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