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Product
Price
Quantity
Subtotal
Gel Wheelchair Cushion
$
30.86
Gel Wheelchair Cushion quantity
$
61.72
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 Universal Walker Tray with Cup Holder
$
54.99
Drive Medical Universal Walker Tray with Cup Holder quantity
$
54.99
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Order Summery
Subtotal
$
216.70
Total
$
216.70
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Medicare Claim Insurance Purchase Request
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Medicaid Claim Insurance Purchase Request
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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
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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Last Name
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DD dash MM dash YYYY
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Medicare
Mediciad
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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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