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Product	Price	Quantity	Subtotal
Molded Wheelchair Cushion General Use	$32.23	Molded Wheelchair Cushion General Use quantity	$32.23
FasciaFix Plantar Fasciitis Relief Sleeve	$25.00	FasciaFix Plantar Fasciitis Relief Sleeve quantity	$25.00
Dexcom G6 Receiver	$375.98	Dexcom G6 Receiver quantity	$375.98
Darco HeelWedge Healing Shoe	$40.00	Darco HeelWedge Healing Shoe quantity	$40.00
FreeStyle Libre 3 Plus Sensor Kit - Pack of 2	$199.99	FreeStyle Libre 3 Plus Sensor Kit - Pack of 2 quantity	$199.99

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Subtotal	$673.20
Total	$673.20

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Workers Comp Claim Insurance Purchase Request

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Insurance Type

Medicare

Mediciad

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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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Date of Birth(Required)

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Insurance Type

Medicare

Mediciad

No Fault

Workers Comp

Other