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Qualifying Product:

Lift Chair Power Wheelchair Scooter

Your Name:
(if you are not the patient)

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Patients First Name:

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Patient’s Last Name

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Patient’s Gender:

Male Female

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Date of Birth:

January February March April May June July August September October November December Month 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Day

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Mailing Address 1:

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Mailing Address 2:

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City:

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State

AK AL AR AZ CA CO CT DE DC FL GA GU HI IA ID IL IN KS KY LA MA MD ME MI MN MS MT ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VI VT WA WI WV WY

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Zip Code

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E-Mail Address:

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Referring Doctor:

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Doctor’s Medical Specialty

General Practitioner Internal Orthopedic Pulmanologist Other

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Patient’s Height:

 Feet    Inches

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Patient’s Weight:

  Pounds Kilograms

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Does Medicare provide you with coverage?

 Yes No

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Type of Medicare Coverage:

Medicare A Medicare B Medicare A & B N/A Other

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Supplemental Insurance Provider: (If none, type “NONE”)

HMO Provider:

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Has Medicare ever provided this or any equipment to you previously?

 Yes No

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If so, what equipment?

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How long has it been since you had the equipment?

 Years Months

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How long did you have the equipment?

 Years Months

Special Requirements, comments, or other information:

*

How did you hear about Mikes Medical?

Friend or relative Internet Search Engine Newspaper Ad Other Radio Ad Television Ad Trade Show Web Site

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