Wheelchair Order Form

Patient Name *

First

Last

Sex

• Male
• Female

Height

Weight

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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

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Physician Name

NPI #

Phone

Fax

Address

Address

City

State

ZIP Code

Submit Form