electric wheel chair, electric wheel chairs

electric wheelchair, electric wheelchair

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Call today to see if you qualify—toll-free (888)298-0661

Qualification Information Form

In order to make the process easy on you, we will verify if your insurance covers electric wheelchairs, and we will get paperwork to your doctor. This way it is easy for you and your doctor! Therefore, if you want to see if you qualify for an electric wheelchair at no cost to you, please fill out the form. Once you submitt the form, a mobility specialist will start the process and contact you within 24 hours.

Information needed: *All information will be kept confidential*

Name
Last Name
Street
City
State
ZIP
Phone number
Email address

Date of Birth
Height
Weight

Medicare Number
Secondary Insurance Name
I don't have secondary insurance	Yes No

Doctor's name
Doctor's Phone number
Doctor' fax
Doctor's Address
Doctor's City
Doctor's State
Doctor's ZIP

All information will be kept confidential

Toll free: (888)298-0661
Email: info@123electricwheelchair.com

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