Apply for Free Equipment — A plus Medical Supply

Medicare Equipment Request Form

A plus Medical Supply · HIPAA Compliant · Secure & Encrypted

Personal Information

* First Name

* Last Name

* Phone Number

* Date of Birth

* Email Address

* Street Address

* City

* State

* ZIP Code

Best Time to Contact

Insurance & Coverage

* Insurance Type

* Medicare / Member ID

Equipment & Condition

* Requested Equipment / Brace

Pain Area / Body Part

Current Symptoms

I agree to be contacted regarding my DME / orthotic brace request. I understand that eligibility may vary based on insurance plan and medical documentation, and that submitting this form does not guarantee approval or coverage.

🔒 Your information is confidential and used only to process your DME / orthotic request. · HIPAA Compliant

Disclaimer: A Plus Medical Supply does not guarantee Medicare coverage or approval. Our team will review your request and verify eligibility with your insurance provider. A specialist may contact you for additional information or documentation. Submitting this form initiates an inquiry only.

Medicare DME Application