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“Drive Medical Adjustable Tension Wheelchair Back Cushion – Customizable Comfort and Support” has been added to your cart.
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Product
Price
Quantity
Subtotal
Drive Medical Adjustable Tension Wheelchair Back Cushion – Customizable Comfort and Support
$
99.99
Drive Medical Adjustable Tension Wheelchair Back Cushion – Customizable Comfort and Support quantity
$
99.99
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
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Order Summery
Subtotal
$
399.98
Total
$
399.98
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Medicare Claim Insurance Purchase Request
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Medicaid Claim Insurance Purchase Request
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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.
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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
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DD dash MM dash YYYY
Insurance Type
Medicare
Mediciad
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Workers Comp
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(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
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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