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Quick Order

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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.


Patient Information

  • Gender
  • Height

Physician Information


Billing Information (Insurance Information)


Items / Service Requested *


File Attachment (Browse to attach a file to your order such as a prescription or other documentation.)


Please fax your prescription for the requested services to **PHONEVARIABLE**. 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.

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