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Product
Price
Quantity
Subtotal
Drive Medical Wheelchair Transport Lightweight
$
229.99
Drive Medical Wheelchair Transport Lightweight quantity
$
229.99
Drive Medical Deluxe Folding Walker, Two Button
$
62.99
Drive Medical Deluxe Folding Walker, Two Button quantity
$
62.99
Dexcom G6 Sensor, 3/Bx
$
360.98
Dexcom G6 Sensor, 3/Bx quantity
$
360.98
Stabilising Knee Sleeve
$
25.00
Stabilising Knee Sleeve quantity
$
25.00
Dexcom G7 Receiver
$
385.99
Dexcom G7 Receiver quantity
$
385.99
Seat Only for Drive
$
39.99
Seat Only for Drive quantity
$
39.99
Cane Soft Foam Offset Handle
$
25.00
Cane Soft Foam Offset Handle quantity
$
25.00
Rollator 3-Wheeled with Pouch and Basket
$
132.51
Rollator 3-Wheeled with Pouch and Basket quantity
$
132.51
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Order Summery
Subtotal
$
1,262.45
Total
$
1,262.45
Proceed to checkout
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Medicare
Medicaid
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Workers Comp
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Medicare Claim Insurance Purchase Request
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Name
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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
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
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
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