Wheelchair Order Form Please enable JavaScript in your browser to complete this form.Patient Name *FirstLastSex *MaleFemaleHegiht *Weight *DOB *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address *Address (copy) *City *State *ZIP Code *Phone *Diagnosis/ICD 10 *Primary Insurance *Primary Insurance Policy# / Group # *Secondary Insurance *Secondary Insurance Policy# / Group # * Equipment Prescribed: Wheelchair *LightweightStandardHeavy DutyWheelchair (copy) *Back Cushion (HCPCS E2611)Seat Cushion (HCPCS E2611)Elevating Leg Rest (HCPCS E0990) OR Heel Loops (HCPCS E0951) *Elevating Leg Rest (HCPCS E0990)Heel Loops (HCPCS E0951)Elevating Leg Rest (HCPCS E0990) OR Heel Loops (HCPCS E0951) *Seat Belt (HCPCS E0978)Anti-tippers (HCPCS E0971)Wheel Lock Extensions (HCPCS E0961)Adjustable Height Arms (HCPCS E0973)All of the aboveOtherSingle Line Text * Physician Information Physician's Signature *DOB *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Physician Name *NPI # *Phone *Fax *Address *Address *City *State *ZIP Code *Submit Form
