Louisiana Medicaid requires the DIP1 when a recipient needs disposable incontinence products. The prescriber selects the products, provides the medical information and signs an attestation of medical necessity. The DME provider then uses the form to request prior authorization through Louisiana Medicaid's e-PA web application.
The prescriber, a physician, nurse practitioner or physician assistant, completes the product selection, medical information and attestation and signs. The DME provider handles the prior authorization submission.
Download the current version from the source each time; forms change without notice.
Prescription Request Form for Disposable Incontinence Products
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
The prescriber, who may be a physician, nurse practitioner or physician assistant. The prescriber selects the incontinence products, completes the medical information and signs the attestation that the products are medically necessary for the recipient.
The prescriber gives the completed form to the DME provider. The DME provider then requests prior authorization through the Louisiana Medicaid e-PA web application, using the DIP1 as the prescription and medical necessity support.