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Product
Price
Quantity
Subtotal
Drive Medical Universal Walker Tray with Cup Holder
$
54.99
Drive Medical Universal Walker Tray with Cup Holder quantity
$
54.99
Drive Medical Silver Sport 1 Wheelchair – Durable and Lightweight
$
194.99
Drive Medical Silver Sport 1 Wheelchair – Durable and Lightweight quantity
$
194.99
Gel Wheelchair Cushion
$
30.86
Gel Wheelchair Cushion quantity
$
30.86
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Order Summery
Subtotal
$
280.84
Total
$
280.84
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Medicare Claim Insurance Purchase Request
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Medicaid Claim Insurance Purchase Request
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Agree
No Fault 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
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
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(Required)
Email
(Required)
Date of Birth
(Required)
DD dash MM dash YYYY
Insurance Type
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Mediciad
No Fault
Workers Comp
Other
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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
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
Best Sellers
Gel Wheelchair Cushion
$
30.86
Drive Medical Universal Walker Tray with Cup Holder
$
54.99
Drive Medical Silver Sport 1 Wheelchair – Durable and Lightweight
$
194.99
Drive Medical Cruiser X4 Wheelchair - Adjustable and Easy-to-Transport
$
299.99
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