Blood Pressure Machine & Kit Order Form

Upper Arm Blood Pressure Monitor with Cuff for Home Use

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Standard Written Order Forms

Submit your order using this online form.

Questions? Use the live chat window (below, lower right) or call 402-408-1990 during business hours, or contact us.

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This field is for validation purposes and should be left unchanged.

Patient Information

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Date of Birth(Required)

Sex(Required)

FEMALE

MALE

Height(Required)

Weight(Required)

Kohll's Rx Location

Which Kohll's Rx Location would the customer prefer to use?(Required)

Omaha - Millard

Omaha - Midtown

Omaha - Downtown

Lincoln, NE

Malvern, IA

Order Information

Blood Pressure Machine

I10 - Hypertension

Patient unable to use manual sphygmomanometer - please state is attached chart notes why

NOTE: Medicaid only covers this with a diagnosis of I10.

NOTE: NOT COVERED BY MEDICARE OR MEDICARE ADVANTAGE PLANS. With proper diagnosis and documentation, Medicaid and some third party insurances cover Blood Pressure Machines.

Length of Need

Diagnosis

Date of Initial Need

Physician's Signature(Required)

Please do not write a dot or a line to bypass a signature. A valid signature is required for insurance.

Date: 03/05/2026

Prescriber Information

Prescriber Name

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Fax(Required)

NPI(Required)

NPI must match the person whose signature appears above.

Chart Notes

Please attach chart notes. In order for insurance to approve your patient's order, every detail filled out above must be documented in the chart notes. If you know an item is missing, please make an addendum before uploading. If you are unable to upload, please fax the chart notes to: 402-895-3155.

Claims will not be submitted to insurance without chart notes.

Drop files here or

Max. file size: 100 MB.

Insurance Demographics / Face Sheet

If you are unable to upload, please fax the information to: 402-895-3155.

Drop files here or

Max. file size: 100 MB.

Comments / Special Instructions

NOTE: Please notify your patient that due to the questions indicated above having "NO" responses, their insurance will deny coverage.