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“Unisex Back Belt with Lumbar Support” has been added to your cart. Continue shopping

Product	Price	Quantity	Subtotal
POLAR CARE COLD THERAPY	$31.59	POLAR CARE COLD THERAPY quantity	$31.59
Blue Jay Adjustable Abdominal Binder	$30.00	Blue Jay Adjustable Abdominal Binder quantity	$30.00
Blue Jay Lumbar Support	$60.00	Blue Jay Lumbar Support quantity	$60.00
FX Pro Walker High Boot	$59.73	FX Pro Walker High Boot quantity	$59.73
Unisex Back Belt with Lumbar Support	$35.10	Unisex Back Belt with Lumbar Support quantity	$35.10

Order Summery

Subtotal	$216.42
Total	$216.42

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Workers Comp Claim Insurance Purchase Request

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Name(Required)

First Name Last Name

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Insurance Type

Medicare

Mediciad

No Fault

Workers Comp

Other

Insurance Provider(Required)

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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

Other Claim Insurance Purchase Request

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Name(Required)

First Name Last Name

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Email(Required)

Date of Birth(Required)

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Insurance Type

Medicare

Mediciad

No Fault

Workers Comp

Other