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“DARCO FX Pro Low Profile Walker Boot” has been added to your cart. Continue shopping

Product	Price	Quantity	Subtotal
Dexcom G6 Receiver	$375.98	Dexcom G6 Receiver quantity	$375.98
Darco Med-Surg Shoe Mens	$25.00	Darco Med-Surg Shoe Mens quantity	$25.00
Blue Jay Universal Thigh Wrap	$25.00	Blue Jay Universal Thigh Wrap quantity	$25.00
CMF OL1000™	$0.00	CMF OL1000™ quantity	$0.00
DARCO FX Pro Low Profile Walker Boot	$62.99	DARCO FX Pro Low Profile Walker Boot quantity	$62.99

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Subtotal	$488.97
Total	$488.97

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Medicare

Mediciad

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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(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