(800) 482-1993

Quick Referral

HOMELINK® appreciates being able to serve patients and caregivers directly. Please use the following form to order any product. Those marked with an * are mandatory fields.
Your Name *
Phone *  
Company *
Email *

Patient Information
SSN   INS/Claim ID # *
Last Name * First Name *
Street * City *
State *
select
Zip *
Home Phone   Alt Phone  
Gender DOB *
RadDatePicker
Open the calendar popup.
Weight (lbs) Height
select
 ft
select
 in

Physician Information
Last Name * First Name *
Phone *   Fax  

Billing Information (Insurance Information)
Insurance Type
select
Company *
Street
City State
select
Zip Phone *  
Contact

Items / Services Requested *
Items: Include Product Number if available
Notes or special instructions

File Attachment
( Browse to attach a file to your order such as a prescription or other documentation )
Upload a File ( .pdf, .tiff, .tif ) ( Max Size : 20MB )


Please fax your prescription for the requested services to 1-866-271-1814. You will be contacted by a HOMELINK Associate to verify this order prior to processing.
Orders are received and processed the same day, however, accounts are updated in the system by the next business day.
Orders are processed 7 am - 7 pm CT. If it is after hours and this order is urgent, please call 800-482-1993 (Group Health) or 800-571-2943 (Work Comp/Auto) and have us paged. We'd be happy to assist you.