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Meet the Assistive Technology Professionals (ATPs) helping you find the perfect equipment.
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Fill the information below and we will contact you to confirm your referral.
Please tell us about yourself.
If available, please upload the script for your requested evaluation here. (PDF Only; Max Size: 5MB)
Please tell us about your patient.
Please upload the patient's face sheet. (PDF Only; Max Size: 5MB)
Medicare Notice: If your patient is using Medicare, some items may require a face-to-face (F2F) visit with the physician.
Who can furnish this insurance information?
Notice: Medicare and many insurances may not pay for equipment or repairs while your patient resides in a nursing home. After completing and submitting this form, an Action Seating & Mobility Customer Care Coordinator will contact your patient as soon as possible to help them decide the best way for them to get what they need.
Are there specific days and times that are best for this patient’s evaluation?
Notice: If no preferred date is chosen, an Action Seating Care Coordinator will contact you to find the best date of evaluation.
Error: Please choose a location before selecting a prefered ATP.