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“Darco Med-Surg Shoe Mens” has been added to your cart. Continue shopping

Product	Price	Quantity	Subtotal
OPTIFLEX ANKLE CPM	$0.00	OPTIFLEX ANKLE CPM quantity	$0.00
FasciaFix Plantar Fasciitis Relief Sleeve	$25.00	FasciaFix Plantar Fasciitis Relief Sleeve quantity	$25.00
Adjustable Cane Offset with Ergonomic Hyperlon Grip	$25.00	Adjustable Cane Offset with Ergonomic Hyperlon Grip quantity	$25.00
Rollator 3-Wheeled with Pouch and Basket	$132.51	Rollator 3-Wheeled with Pouch and Basket quantity	$132.51
Darco Med-Surg Shoe Black Square-Toe	$19.27	Darco Med-Surg Shoe Black Square-Toe quantity	$19.27
Softie Surgical Shoe Mens	$16.12	Softie Surgical Shoe Mens quantity	$16.12
Darco Med-Surg Shoe Mens	$25.00	Darco Med-Surg Shoe Mens quantity	$25.00

Order Summery

Subtotal	$242.90
Total	$242.90

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Which insurance do you have?

Medicare

Medicaid

No Fault

Workers Comp

Other

Medicare 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

Medicaid 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

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)

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

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