Medicare Eligibility Guidelines | Medicare Info Request

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Fill out the simple form below, and let us help determine if you may be eligible for a Power Wheelchair or Mobility Scooter covered by Medicare. Our Medicare consultants will contact you within one business day to discuss your specific case, with no pressure and no obligation. They can explain the Medicare guidelines, and work with you and your doctor to determine which product is the right product to best meet your needs.

Caregiver Name (if applicable) Caregiver Relationship (if applicable)

Caregiver Phone (if applicable)

First Name (required) Last Name (required) Contact Phone (required) Contact E-mail (required)

Address 1 Address 2 City State Zip

1) My primary insurance is: 2) I am interested in the following items(s): 3) Has Medicare ever provided a similar item for this beneficiary: 4) The item requested is for use: 5) Do you have problems completing any of the following tasks inside your home?

Dressing	Grooming
Eating	Toileting

6) Are you able to propel yourself in a manual wheelchair? Yes No 7) What time is most convenient for you to receive a call?

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Our rental & insurance services cover San Fernando Valley and Los Angeles

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Here are the brands that we carry Acorn Stairlifts, Action Products, Aetrex, Amigo, Apex-Carex, Bort Medical, Clarke Healthcare, Colours, Dana Douglas, Drive, Duro-Med Industries, Eagle Health, EasyStand, EZ-Access, First Quality, FLA Orthopedics, Gaymar, Golden Technologies, Harmar, Health Craft, Inogen, Invacare, Jobst, Keen Mobility, Liko, Medela, Medline, Merry Walker, MK Battery, Moen, Nova Ortho-Med, Obus Forme, Permobil, Pride Mobility, ResMed, Respironics, Seca, SeQual, Shoprider, Smiths Medical, Standers, Sunrise Medical, The Roho Group, Volker, Walk Easy

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