Submit A Service Request
Contact Person
Fields marked with (*) are required.
Contact Name*:
Contact Phone #*: ( ) -
Best time to contact: between and
Email Address:
Client Information
Client Name:
(If different than contact name)
Home Address*:

City: State:
 Zip:
Phone #: ( ) -
(If different than contact phone)
Best time to see at home: between and
Can service be done at an alternate location? If so, where? Yes
No
Best time to see at this location: between and
Which chair needs repair?
Description of the needed repair:
Funding Information
Funding Type:
Health Insurance Private Pay
Medicaid Other
Insurance or funding name:
Policy Number:

Custom Mobility Service Policy:
Funding verification must be done before services are rendered. This includes: Insurances, Medicaid, CMA, Voc Rehab, Med Waiver, MDA, Worker's Compensation, VA, etc. Approval times may vary based on your health plan.

No service will be started until funding is secured.

Cash, checks, credit cards, and money orders are acceptable forms of payment.

Your information will be transmitted securely and will be kept confidential. You may have to add our security certificate to your computer in order to send the form--this is perfectly safe and will ensure that your data is transmitted securely. Please see our privacy policy if you have any questions.