Medicare Qualification form for your independent mobility.
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medicare qualification

 

Medicare Information:
  Generally, you are eligible for Medicare if you or your spouse worked for at least 10 years in Medicare-covered employment, you are 65 years of age, and a citizen or permanent resident of the United States. You may also qualify for Medicare if you are totally and permanently disabled and have been receiving Social Security disability payment for two years, or if you suffer from End-Stage Renal Disease.


  Medicare consists of two parts, part A and part B. Part B requires you to pay an annual premium, however it is part B that covers payment of Durable Medical Equipment (Power Chairs and Scooters).


  Qualifying for a Power Chair or Scooter: In order to qualify for coverage by Medicare, the following conditions must be met:
1. The beneficiary requires the use of a wheelchair to move around in their residence,
2. The beneficiary is unable to operate a wheelchair manually, and
3. The beneficiary can safely operate a Power Chair or Scooter


* Please contact one of our sales representatives for more detailed information.
If you qualify, Medicare will pay for 80% of the cost of a new Chair or Scooter. If you have supplemental insurance, such as Medicaid or private insurance, most often they will pay the remaining 20% of the cost of the chair.

  Call one of our knowledgeable sales representatives to find out if you qualify for Medicare reimbursement. Plus, we handle all the Medicare reimbursement paperwork so you don't have to.

Qualification Inquiry Form: Please submit the following questionnaire to see if you qualify for free power chair or scooter. The Qualification Inquiry form is available online as a Portable Document Format (PDF).

First Name:
Last Name:
Email Address:
Telephone #:
Who is the scooter for?
Any medical conditions?
Who is your insurance provider?
If Medicare, do you have part B coverage?
YES    NO
Do you have supplemental Insurance?
YES    NO
If so, with whom?
Are you interested in a chair or scooter?
Please list any Comments:

 

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