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“Underpads Economy 150/cs” has been added to your cart.
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Product
Price
Quantity
Subtotal
Forearm Crutch- Adj Forearm
$
42.32
Forearm Crutch- Adj Forearm quantity
$
42.32
Drive Medical Cruiser X4 Wheelchair - Adjustable and Easy-to-Transport
$
299.99
Drive Medical Cruiser X4 Wheelchair - Adjustable and Easy-to-Transport quantity
$
299.99
Eggcrate Wheelchair Cushion with Back
$
30.00
Eggcrate Wheelchair Cushion with Back quantity
$
30.00
Gel Wheelchair Cushion
$
30.86
Gel Wheelchair Cushion quantity
$
30.86
Underpads Economy 150/cs
$
51.32
Underpads Economy 150/cs quantity
$
51.32
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Order Summery
Subtotal
$
454.49
Total
$
454.49
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Medicaid
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Workers Comp
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Medicare Claim Insurance Purchase Request
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Max. file size: 2 GB.
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Agree
Medicaid Claim Insurance Purchase Request
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(Required)
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(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
No Fault Claim Insurance Purchase Request
To complete this order we need some information, please fill out below to the best of your ability and our team will contact you if there are any additional requirements.
Name
(Required)
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(Required)
DD dash MM dash YYYY
Insurance Type
Medicare
Mediciad
No Fault
Workers Comp
Other
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(Required)
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(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
Workers Comp Claim Insurance Purchase Request
To complete this order we need some information, please fill out below to the best of your ability and our team will contact you if there are any additional requirements.
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
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
To complete this order we need some information, please fill out below to the best of your ability and our team will contact you if there are any additional requirements.
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
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
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