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“Drive Medical Go-Lite Bariatric Steel Rollator with 8″ Wheels” has been added to your cart. Continue shopping

Product	Price	Quantity	Subtotal
EZ Adjust Alum Crutches	$44.99	EZ Adjust Alum Crutches quantity	$44.99
Drive Medical Go-Lite Bariatric Steel Rollator with 8" Wheels	$169.99	Drive Medical Go-Lite Bariatric Steel Rollator with 8" Wheels quantity	$169.99

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Subtotal	$214.98
Total	$214.98

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Workers Comp Claim Insurance Purchase Request

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Name(Required)

First Name Last Name

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Email(Required)

Date of Birth(Required)

DD dash MM dash YYYY

Insurance Type

Medicare

Mediciad

No Fault

Workers Comp

Other

Insurance Provider(Required)

Insurance ID(Required)

Documents Section Upload (i.e. prescriptions)

Max. file size: 2 GB.

I agree to allow CapsuleAID and its authorized representatives to contact me about my medical supplies, orders, and related subject.(Required)

Agree

Other Claim Insurance Purchase Request

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Name(Required)

First Name Last Name

Phone Number(Required)

Email(Required)

Date of Birth(Required)

DD dash MM dash YYYY

Insurance Type

Medicare

Mediciad

No Fault

Workers Comp

Other