411PowerChairs

*I am interested for:
*My First Name:
*My Last Name:
*Address:
*Zip:
*Home Phone:	- -
Alternative Phone (Optional):	- -
*Email Address:
*Insurance Carrier:

Are you unable to walk or is it too unsafe or painful for you to do so?	Yes No
Can you propel a manual wheel chair?	Yes No
Do you/friend currently live in a Nursing Home or are under Hospice Care?	Yes No
Can you use a cane or walker?	Yes No

As a contracted Medicare provider and insurance coverage specialist, we will process all paperwork on your behalf, including assistance with obtaining authorization from your physician.

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► Free Setup!
► Free Insurance Filing!

** Actual cost depends on insurance provider benefits.