TRICARE Extended Care Health Option (ECHO)
Incontinence Supplies Service Request and Notification Form
Please use this form when requesting incontinence supplies for a TRICARE West Region beneficiary
enrolled in the TRICARE ECHO program. You can find information on the ECHO program at
tricare.mil/echo.
Fax this form to 877-890-8156. If you have questions, please contact ECHO and Specialized Case
Management at 855-874-6800. Thank you.
Beneficiary Information
Last Name:
First Name:
MI:
Gender:
City:
Date of Birth (mm/dd/yyyy):
Address:
Apt.
State:
ZIP code:
Phone Number:
Sponsor’s Department of Defense (DoD) Benefits
Number:
Requesting Care Provider
Name:
National Provider Identifier (NPI):
Tax Identification Number (TIN):
Address:
Office/Suite:
City:
Contact Last Name:
Contact First Name:
Office Phone Number:
Office Fax:
State:
ZIP code:
Rendering Care Provider or Vendor (durable medical equipment company)
No preference; defer to an available network durable medical equipment provider
Name:
National Provider Identifier (NPI):
Tax Identification Number (TIN):
Address:
Office/Suite:
City:
State: ZIP code:
This document may contain personally identifiable information, including protected health information. Only those with
a need to know should access or use this document. Access, use or disclosure of this document or its contents must
comply with the MHS Notice of Privacy Practices, the HIPAA Privacy Rule and the DoD Privacy Program. If you
received this document in error, please contact us immediately at 877-988-9378. Quality Assurance document under
10 USC 1102. Copies of this document, enclosures and information will not be further released under penalties of
law. Unauthorized disclosure carries a possible $3,000 fine.
TRICARE West Region Customer Service: 877-988-9378 (WEST) – UHCMilitaryWest.com
“TRICARE,” “TRICARE Prime,” “TRICARE Reserve Select” and “TRICARE Retired Reserve” are registered
trademarks of the Defense Health Agency. All Rights Reserved.
PCA19070_20151027
MVF10083_09012015-80
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TRICARE Extended Care Health Option (ECHO)
Incontinence Supplies Service Request and Notification Form
Office Phone Number:
Office Fax:
Service Request Information
Diagnosis: ________________________
ICD-10-CM_________________
Beneficiary Weight: ________________
Beneficiary Waist Size (inches for adults): _______________
Choose one:
Anticipated start date of service
Re-authorization of Services Approved: anticipated start date of continuation of services
Change of Service: anticipated start date of change of services
Items
Requested
Incontinence Supply Description
(with beneficiary waist or weight guidelines)
HCPCS
Code
T4521
T4522
T4523
T4524
T4525
T4526
T4527
T4528
T4529
T4530
Units Per Day
(Unit equals one
diaper/garment)
Adult size disposable incontinence product, brief/diaper
Size: small (waist 20-36 inches)
Adult size disposable incontinence product, brief/diaper
Size: medium (waist 32-44 inches)
Adult size disposable incontinence product, brief/diaper
Size: large (waist 45-58 inches)
Adult size disposable incontinence product, brief/diaper
Size: extra-large (waist 59-64 inches)
Adult size disposable incontinence product, underwear/pull-on
Size: small (waist 20-36 inches or 60-125lbs)
Adult size disposable incontinence product, underwear/pull-on
Size: medium (waist 34-48 inches or 120-175 lbs.)
Adult size disposable incontinence product, underwear/pull-on
Size: large (waist 44-58 inches or 170-210 lbs.)
Adult size disposable incontinence product, underwear/pull-on
Size: extra-large (waist 59-64 inches)
Pediatric sized disposable incontinence product, brief/diaper
Size: small/medium (12-28 lbs.)
Pediatric sized disposable incontinence product, brief/diaper
Size: large (22-37 lbs.)
This document may contain personally identifiable information, including protected health information. Only those with
a need to know should access or use this document. Access, use or disclosure of this document or its contents must
comply with the MHS Notice of Privacy Practices, the HIPAA Privacy Rule and the DoD Privacy Program. If you
received this document in error, please contact us immediately at 877-988-9378. Quality Assurance document under
10 USC 1102. Copies of this document, enclosures and information will not be further released under penalties of
law. Unauthorized disclosure carries a possible $3,000 fine.
TRICARE West Region Customer Service: 877-988-9378 (WEST) – UHCMilitaryWest.com
“TRICARE,” “TRICARE Prime,” “TRICARE Reserve Select” and “TRICARE Retired Reserve” are registered
trademarks of the Defense Health Agency. All Rights Reserved.
PCA19070_20151027
MVF10083_09012015-80
UHCMV10331_11182015
2 of 3
TRICARE Extended Care Health Option (ECHO)
Incontinence Supplies Service Request and Notification Form
T4531
T4532
T4533
T4534
Pediatric sized disposable incontinence product, underwear/pull-on
Size: small/medium (size 2T-3T or 18-34 lbs.)
Pediatric sized disposable incontinence product, underwear/pull-on
Size: large (size 3T-4T or 32-40 lbs.)
Youth size disposable incontinence product, brief/diaper
(size 6-7 or 18-35 lbs. plus )
Youth size disposable incontinence product, underwear/pull-on
(size 4T-5T or more than 38 lbs.)
T4535
Disposable liner/shield/guard/pad/undergarment for incontinence
T4536
Incontinent product, reusable protective underwear/pull-up or pullon, any size
T4539
Incontinence product, diaper, brief, reusable, any size
T4343
T4544
A4520
Adult sized disposable incontinence product, protective brief/diaper
Size: above extra-large (waist 63-90 inches)
Adult sized disposable incontinence product, protective
underwear/pull-on,
Size: above extra-large (waist 68-80 inches or more than 210 lbs.)
Incontinence garment, any type (for instance: brief, diaper)
Pricing Information
Cost Per Unit (excluding shipping and tax):
Shipping Cost (Monthly):
Tax Per Shipment:
This document may contain personally identifiable information, including protected health information. Only those with
a need to know should access or use this document. Access, use or disclosure of this document or its contents must
comply with the MHS Notice of Privacy Practices, the HIPAA Privacy Rule and the DoD Privacy Program. If you
received this document in error, please contact us immediately at 877-988-9378. Quality Assurance document under
10 USC 1102. Copies of this document, enclosures and information will not be further released under penalties of
law. Unauthorized disclosure carries a possible $3,000 fine.
TRICARE West Region Customer Service: 877-988-9378 (WEST) – UHCMilitaryWest.com
“TRICARE,” “TRICARE Prime,” “TRICARE Reserve Select” and “TRICARE Retired Reserve” are registered
trademarks of the Defense Health Agency. All Rights Reserved.
PCA19070_20151027
MVF10083_09012015-80
UHCMV10331_11182015
3 of 3