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Product
Price
Quantity
Subtotal
Theratherm Moist Heat Pad
$
92.90
Theratherm Moist Heat Pad quantity
$
92.90
Drive Medical Deluxe Dual Trigger Release Folding Walker for Adults
$
63.60
Drive Medical Deluxe Dual Trigger Release Folding Walker for Adults quantity
$
63.60
Drive Medical Deluxe Folding Walker, Two Button
$
62.99
Drive Medical Deluxe Folding Walker, Two Button quantity
$
62.99
Adjustable Cane with Vinyl Grip
$
35.00
Adjustable Cane with Vinyl Grip quantity
$
35.00
Ice It!® ColdCOMFORT System with Adjustable Strap
$
33.18
Ice It!® ColdCOMFORT System with Adjustable Strap quantity
$
33.18
Softie Surgical Shoe Mens
$
16.12
Softie Surgical Shoe Mens quantity
$
16.12
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Order Summery
Subtotal
$
303.79
Total
$
303.79
Proceed to checkout
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Medicare Claim Insurance Purchase Request
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Medicaid Claim Insurance Purchase Request
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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
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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(Required)
DD dash MM dash YYYY
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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
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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Adjustable Cane with Vinyl Grip
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