Urology Supplies Order Form

Home

Customer Service

Standard Written Order Forms

Instructions here. Explain what happens after the form is submitted and what to expect.

Questions? Please call 402-408-1990.

Phone

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

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

Patient Insurance Information

Primary Insurance Name

Primary Insurance ID#

Secondary Insurance Name

Secondary Insurance ID#

Diagnosis

Primary Diagnosis

R32 - Unspecified Urinary Incontinence

33.9 - Retention of Urine

ICD10

Description

Date of Initial Need(Required)

Length of Need(Required)

Months

Lifetime

Urology Order(Required)

Intermittent Straight Catheter Quantity(Required)

Intermittent Straight Catheter Frequency(Required)

Per Day

Per Month

Other

Intermittent Straight Catheter French Size(Required)

Justification for Coude Catheter(Required)

Patient must have Retention as well as

Urethral Strictures

Enlarged Prostate

Scar Tissue Build Up

Other

Intermittent Coude Catheter Quantity(Required)

Intermittent Coude Catheter Frequency(Required)

Per Day

Per Month

Other

Intermittent Coude Catheter French Size(Required)

Closed System Straight Tip Quantity(Required)

Closed System Straight Tip Frequency(Required)

Per Day

Per Month

Other

Closed System Straight Tip French Size(Required)

Closed System Coude Tip Quantity(Required)

Closed System Coude Tip Frequency(Required)

Per Day

Per Month

Other

Closed System Coude Tip French Size(Required)

Male External Catheter Size(Required)

Male External Catheter Quantity(Required)

Male External Catheter Frequency(Required)

Per Day

Per Month

Other

Foley Catheter Size(Required)

Foley Catheter Quantity(Required)

Foley Catheter Frequency(Required)

Per Day

Per Month

Other

Foley Catheter French Size(Required)

Foley Insertion Kit Size(Required)

Foley Insertion Kit Quantity(Required)

Foley Insertion Kit Frequency(Required)

Per Day

Per Month

Other

Foley Irrigation Tray Size(Required)

Foley Irrigation Tray Quantity(Required)

Foley Irrigation Tray Frequency(Required)

Per Day

Per Month

Other

Leg Bags Size(Required)

Leg Bags Quantity(Required)

Leg Bags Frequency(Required)

Per Day

Per Month

Other

Drain Bags Size(Required)

Drain Bags Quantity(Required)

Drain Bags Frequency(Required)

Per Day

Per Month

Other

Lubricant Size(Required)

Lubricant Quantity(Required)

Lubricant Frequency(Required)

Per Day

Per Month

Other

Incontinence

Medicaid Only

Briefs (tabbed)

Briefs (pull-ups)

Underpads

Gloves

Liners

Briefs (tabbed) Size(Required)

Briefs (tabbed) Quantity

Briefs (tabbed) Frequency

One time

Per month

Other

Briefs (pull-ups) Size(Required)

Briefs (pull-ups) Quantity

Briefs (pull-ups) Frequency

One time

Per month

Other

Underpads Size(Required)

Underpads Quantity

Underpads Frequency

One time

Per month

Other

Gloves Size(Required)

Gloves Quantity

Gloves Frequency

One time

Per month

Other

Liners Size(Required)

Liners Quantity

Liners Frequency

One time

Per month

Other

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(Required)

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.

Please note: Medicare grade documentation may be needed.

Discrete Delivery Version 12.10.17

Comments / Special Instructions