Hospital Bed Order Form

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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.

Name

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)

Month

Day

Year

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

Qualifications

1. Does the patient have a medical condition which requires positioning of the body in ways not feasible with an ordinary bed?(Required)

YES

NOTE: Your patient's insurance will deny coverage if the answer to this question is "NO."

2. Does the patient require positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain?(Required)

YES

3. Does the patient require the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with aspiration?(Required)

YES

NOTE: Your patient's insurance will deny coverage if the answer to this question is "NO."

4. Does the patient require traction equipment that can only be attached to a hospital bed?(Required)

YES

5. Does the patient require a bed height different from a fixed height hospital bed to permit transfers to chair, wheelchair, or standing position?(Required)

YES

6. Does the patient require frequent changes in body position?(Required)

YES

NOTE: Your patient's insurance will deny coverage if the answer to this question is "NO."

7. Have all alternatives such as wedges, pillows and other supports been ruled out?(Required)

YES

Pressure Reducing Support Surfaces

5 Zone Therapeutic Mattress

Low Air Loss Mattress

Other - please specify

Other Support Surface(Required)

1. Is the patient completely immobile?(Required)

i.e. patient cannot make changes in body position without assistance

YES

2. Does the patient have limited mobility?(Required)

i.e. the patient cannot independently make changes in body position significant enough to alleviate pressure.

YES

NOTE: Your patient's insurance will deny coverage if the answer to both questions 1 and 2 are "NO."

3. Does the patient have any pressure ulcer(s) on the trunk or pelvis?(Required)

YES

4. Does the patient have impaired nutritional status?(Required)

YES

5. Does the patient have fecal or urinary incontinence?(Required)

YES

6. Does the patient have altered sensory perception?(Required)

YES

7. Does the patient have compromised circulatory status?(Required)

YES

NOTE: Your patient's insurance will deny coverage if the answer to all questions 3-7 are "NO."

Length of Need

Diagnosis

Date of Initial Need

MM slash DD slash YYYY

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

Acknowledgement(Required)

I certify that the above prescribed equipment and/or supplies are reasonable and medically necessary as part of treatment for this patient.

The need and medical necessity for the above listed equipment and/or supplies is documented in the patient’s medical record and it is available upon request.

All information provided in this form is also addressed in the patient's medical records. I acknowledge the patient's medical equipment will be denied by their insurance if the chart notes do not properly match the information entered above.

(If any information is missing in the chart notes, please make accurate addendums before uploading them)

I agree to the above.

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