Your Personal Health Record

Power Chair Details

* = required

• * Equipment Name:
• * Model Name:
• Model Number:
• Serial Number:
• Cost: $
• Purchased:
• Vendor:
• Vendor Phone:
• Vendor Website:
• Vendor Email:
• Vendor Address:
• Notes: Medicaid paid $2500, OVR paid balance. Due for replacement in 2017. Call Newmotion for repairs and maintenance. See attached delivery ticket for details and specifications.
• Attachments: Delivery ticket for power chair   [delete]

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