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Product
Price
Quantity
Subtotal
Colpac-Polyurethane Covered
$
26.87
Colpac-Polyurethane Covered quantity
$
26.87
Dexcom G6 Transmitter
$
249.98
Dexcom G6 Transmitter quantity
$
249.98
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
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Order Summery
Subtotal
$
340.45
Total
$
340.45
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Workers Comp Claim Insurance Purchase Request
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(Required)
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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.
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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)
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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
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