New CareLinc Equipment Order

Every piece of equipment we offer is different and unique. To deliver the correct item the first time and be able to bill your insurance - we really should have a conversation about what you are looking for! Send us your contact info and we’ll call you to get started!

Service To:
PLEASE NOTE: CARELINC MEDICAL services the following states ONLY: MICHIGAN, OHIO (Hospice/LTC), SOUTHERN REGION (Hospice/LTC)
Patient Name*
First Last
Patient's Date of Birth*
MM
DD
YYYY
Phone*
Email*
Your Name*
First Last
If not the same as "Patient Name"
Patients Address*
Street Address Address Line 2 City State ZIP Code

ANY OUT OF STATE ORDERS CANNOT BE PROCESSED THROUGH CARELINC. PLEASE CONTACT A LOCAL DME PROVIDER WITHIN YOUR STATE. Thank you!
Equipment item(s) needed for the patient:*
Item 1 Item 2 Item 3
Do you have a prescription/referral/Dr.'s order being placed with us for the item(s)?*
Because we are a DME supplier who's able to bill to insurance, many of the items we provide, do require us to have a prescription and qualifying documentation on file first before we are able to provide you with this item. If you haven't spoken to your physician about this item, please do so before submitting this form if you will not be privately paying. If you have any questions, concerns or if you are interested in how to go about ordering in general, please feel free to ask us in the comments section below!
Comments
Comments
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Item 1	Item 2	Item 3