Regain your Independence with an Electric Wheelchair from The Wheelchair Alliance

Qualify for a Power Wheelchair - The Wheelchair Alliance

*Your First Name:

*Your Last Name:

*Your Phone Number:
- -
*Email:

*Address:

*City:

State: Zip:

*Primary Insurance Provider:

Comments:

*Have you had a power chair paid for by your insurance in the past 5 years?
Yes No
*Do you live in a nursing home or hospice?
Yes No
*Do you feel your physician would prescribe you a power chair?
Yes No

A mobility specialist will call you shortly *Required Field
I would like to receive The Wheelchair Alliance Health Partners Newsletter:
Yes

Your health insurance company may cover a portion of the costs for an Electric Wheelchair depending on your medical condition and insurance benefits.

You may be able to qualify for a power wheelchair if:

You suffer from limited mobility to such an extent that you can not use a cane, walker, or manual wheelchair.
Your Doctor feels it is necessary for you to use a power wheelchair and he/she will write a prescription.

If so, you may qualify for an electric wheelchair for little or no cost to you through your insurance. Submit the form, talk to us and find out. It's simple, it's fast and no obligation to you.

Fill out the form and find out if you can qualify! >>

After you submit this form, a mobility specialist from a member of The Wheelchair Alliance will call you for a free no-risk phone consultation. We will help you find out if you qualify for an electric wheelchair at little or no cost to you. If you are a good candidate, then we will walk you through the process.

**By submitting this form, you agree to allow Orbit Medical, The Wheelchair Alliance and its partners to use the supplied contact information to contact you about products and services provided by Orbit Medical, The Wheelchair Alliance and its partners. You also agree to the privacy policy.

Terms and Conditions | Privacy Policy