Health Professionals

Photo of doctor talking to two patients

Helping Your Patients Live Better

You can trust Arkansas Medical Supply to provide quality products for your patients.

We provide latex-free products and friendly, personal service. Our goal is to help your patients live better.

At Arkansas Medical Supply, we offer several referral options for your convenience:

  • Fill out the form at the bottom of this page
  • Email us at info@arkansasmedicalsupply.com
  • Call us at 501-227-8220 or 800-467-7446
  • Fax your patient’s information to 501-227-6260

 

Arkansas Medical Supply also provides a wide variety of diagnostic and nursing supply products.

Request for Patient Referral

Please complete the form below and click "Submit" when finished. We will contact you for additional information. If you prefer to print and fax your referral, a PDF version is available here.


Intake Form
  1. Person Making Referral




  2. Client



  3. Physician Ordering Referral









  4. Supplies for Client
  5. Urological
  6.  times/day
  7. Incontinence
  8.  lbs
  9. Additional Information
  10. Has the client ever received the same or similar supplies?

  11. Previous Supplies Provider



  12. Is the item being replaced?
  13. Insurance Information
  14. Is the client enrolled in a Medicare, Medicaid, HMO/PPO or private insurance program?
  15. Primary Insurance


  16. Secondary Insurance


  17. Payment
  18. Is the client aware of the deductible and copayment responsibility?
  19. Arkansas Medical Supply will provide ostomy supplies non-assigned. Would the client like additional information on non-assignment?