Wheelchair Order Form

Patient Name *

First

Last

Sex *

• Male
• Female

Hegiht *

Weight *

DOB *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

Address *

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 *

• Lightweight
• Standard
• Heavy Duty

Wheelchair (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 above
• Other

Single Line Text *

Physician Information

Physician's Signature *

DOB *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

Physician Name *

NPI # *

Phone *

Fax *

Address *

Address *

City *

State *

ZIP Code *

Submit Form