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Product
Price
Quantity
Subtotal
Drive Medical Silver Sport 1 Wheelchair – Durable and Lightweight
$
194.99
Drive Medical Silver Sport 1 Wheelchair – Durable and Lightweight quantity
$
194.99
OMRON 3 Series Arm Blood Pressure Monitor
$
59.53
OMRON 3 Series Arm Blood Pressure Monitor quantity
$
59.53
OMRON 5 Series Upper Arm Blood Pressure Unit
$
81.27
OMRON 5 Series Upper Arm Blood Pressure Unit quantity
$
81.27
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Subtotal
$
335.79
Total
$
335.79
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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
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(Required)
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Insurance Type
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Mediciad
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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
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
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(Required)
DD dash MM dash YYYY
Insurance Type
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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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