Insurance Qualification Form

 If you or someone you know would like to discover 
if they qualify for a new power wheelchair or 
scooter to be paid for by Medicare or 
private insurance .....

Just fill in the form below and we will let you know right away! 
or call us TOLL FREE at

1-800-449-8991

It's as easy as 1...2...3...

  1. Give us your information below and the required paperwork will be sent to your doctor to complete. You will receives some brochures on our products as well as an  insurance claim form and other papers to sign. Choose the mobility product that you think best suits your needs, then sign and mail all of the documents back in the  postage paid envelope provided.
  2. We will contact you as soon as we have received your paperwork and the qualifying paperwork from your doctor. Rest assured...nothing will be shipped to you or billed to your insurance without YOUR final approval!!
  3. Once you have given your approval, we will ship the mobility equipment to you fully assembled, and bill your insurance company.

That's all there is to it!!

You can complete and submit this form online or.......

Call Us Toll Free at:

1-800-449-8991

E-mail Us at:

sales@americanwheelchairs.com

 

Please take a moment of your time to let us  know how you found us:

Through an internet banner advertisement.

Through an internet search.

Through a magazine advertisement

Through postcard in the mail.

Other

Please enter your name

First name:   

Middle initial:    Last name:   

Please give us your mailing address:

Address 1:   

Address2:   

City:   

State:      ZIP/Postal code:

Please enter your shipping address: (Must list street address, P.O. Boxes are not accepted)

Address 1:   

Address2:   

City:   

State:      ZIP/Postal code:

Please enter your contact information:

E-mail address:   

Phone number:   

Fax number:   

Is Medicare your primary insurance?

Yes

No

If yes, please enter your Medicare ID number ( this is your social security number followed by a letter or number and is located on your red white and blue Medicare card).

Medicare ID number:   

If no, please fill in the following information on your insurance company.

Company name:   

Claim mailing address:

Address 1:   

Address2:   

City:   

State:      ZIP/Postal code:

Phone number:   

Please list you group and/or policy number:

Group number:   

Policy number:   

If Medicare is your primary insurance but you also have secondary insurance, please fill in the section below on your secondary insurance.

Company name:   

Claim mailing address:

Address 1:   

Address2:   

City:   

State:      ZIP/Postal code:

Phone number:   

Please list you group and/or policy number:

Group number:   

Policy number:   

Do you need the scooter or wheelchair for:

Indoor Use

Outdoor Use

Both Indoors and Outdoors

 

Please enter your height, weight and date of birth.

Height:   Ft.    In.     Weight   lbs.

Date of birth:   

Are you:

Right Handed

Left Handed 

Has Medicare rented or purchased a manual wheelchair for you in the last 5 years?

Yes

No

Please enter the following information on your doctor:

Doctors name:   

Mailing address:

Address 1:   

Address2:   

City:   

State:      ZIP/Postal code:

Phone number:   

Fax number:     

Please select the wheelchairs) you would like information on

Additional questions and comments:

Thank You!