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“Unisex Back Belt with Lumbar Support” has been added to your cart. Continue shopping

Product	Price	Quantity	Subtotal
Stabilising Knee Sleeve	$25.00	Stabilising Knee Sleeve quantity	$25.00
KINETIC MAESTRA HAND & WRIST CPM	$0.00	KINETIC MAESTRA HAND & WRIST CPM quantity	$0.00
ObusForme Back Support Belt with Built-in Lumbar Support	$48.32	ObusForme Back Support Belt with Built-in Lumbar Support quantity	$48.32
Unisex Back Belt with Lumbar Support	$35.10	Unisex Back Belt with Lumbar Support quantity	$35.10

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Subtotal	$108.42
Total	$108.42

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Workers Comp Claim Insurance Purchase Request

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Name(Required)

First Name Last Name

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Insurance Type

Medicare

Mediciad

No Fault

Workers Comp

Other

Insurance Provider(Required)

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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

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Email(Required)

Date of Birth(Required)

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Insurance Type

Medicare

Mediciad

No Fault

Workers Comp

Other