City Wheelchairs

Categories

Manual Wheelchairs (8)
Power Wheelchairs-> (14)
Heavy Duty/Bariatric Mobility (11)
Scooters (16)
Accessories, Rollators, Ramps-> (18)
Wheelchair Lifts & Ramps (7)
Wheelchair Parts (1)

Manufacturers

What's New?

Pride Celebrity X 4 Wheel
$2,099.00

Quick Find

Online Medicare Qualification Form

Personal Information

What Type of Wheelchair would you like to qualify for?
First Name:
Middle Init.:
Last Name:
Street Address1:
Street Address2:
City:
State (2-letter code):
5-digit Postal Code:
Country (2-letter code):
Phone Number:
Fax Number:
Email Address:
Height:	Ft: In:
Weight:	in Lbs
Date Of Birth:

Primary Insurance Information

Medicare is My Primary Insurance

If yes, please enter your Medicare ID Number (hint: 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:

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

Company Name:
Claims Mailing Address:
City:
State (2-letter code):
5-digit Zip Code:
Phone Number:
Group Number:
Policy Number:

Secondary Insurance Information

If Medicare is your primary insurance and you have a secondary insurance, please fill in the section below.

Company Name:
Claims Mailing Address:
City:
State (2-letter code):
5-digit Zip Code:
Phone Number:
Group Number:
Policy Number:

Physician Information

Physician Name:
Mailing Address:
City:
State (2-letter code):
5-digit Zip Code:
Phone Number:
Fax Number:

Other Comments:

Shopping Cart

0 items

Medicare Form
Medicare Info

Information

Shipping & Returns
Privacy Notice
Useful Links
Contact Us

Bestsellers

01.	Lightweight Aluminum Transport
02.	Tracer® EX2
03.	9000SL
04.	Pronto® M94 Bariatric
05.	Tracer® SX5
06.	Tracer® Transport Chair
07.	350ARV ALUMINUM!!
08.	ICR330 3 Foot Folding Ramp
09.	ICR330 3 Foot Folding Ramp
10.	ICR630 6 Foot Folding Ramp