Schedule an Evaluation | Action Seating & Mobility

For whom are you filling this form? I am filling this form for myself or a loved one. I am a medical professional and I'm filling this form for a patient.

Notice: Medicare and many insurances may not pay for equipment or repairs while you reside in a nursing home. After completing and submitting this form, an Action Seating & Mobility Customer Care Coordinator will contact you as soon as possible to help you decide the best way for you to get what you need.

Therapist Information

Please select the option that best applies to you. I have a therapist that will accompany me during my evaluation. I do not have a therapist and would like a referral.

Please fill this information about the therapist.

First Name

Last Name

Credentials

Clinic

Phone

Email

Address

Suite, apartment, etc.

City

State

Zip Code

Tell us About Your Equipment Needs

Select an option that best describes your equipment needs. I need new assistive equipment. I need my current assistive equipment repaired.

What type of equipment do you need?

Other

Please include any details we may need prior to your appointment.

Will you require a demonstration of your new equipment? Yes No

Make of Current Equipment

Model of Current Equipment

Purchase Date of Current Equipment

Describe the problems you're experiencing with your current equipment.

Insurance Information

Select the option that best applies to your insurance coverage. I have insurance coverage. I plan on paying out of pocket.

Primary Insurance Name

Primary Insurance #

Primary Insurance Group #

Secondary Insurance Name

Secondary Insurance #

Secondary Insurance Group #

Other Payer Insurance Name

Other Payer Insurance #

Other Payer Group #

Insurance Card Photos

For all insurances provided, please upload a corresponding photo.

Medicare Notice: If you're using Medicare, some items may require a face-to-face (F2F) visit with the physician.

Preferred Date of Evaluation

Notice: This is not a final schedule for your appointment. A Customer Care Coordinator will be in contact with you to set a date and time for your appointment that best aligns with our evaluation schedule and your preferred date.