Medicare Beneficiary Wheelchair Repair Survey

This survey is being done to gather information on the ability of Medicare beneficiaries to get timely repairs to their wheelchairs. The results will be shared with Medicare officials and policymakers. Thank you for your participation!

The questions with asterisks are required and the survey cannot be completed without responding to those questions.

Question Title

* 1. Please provide the following information:

Name:

Email Address:

Phone Number:

Question Title

* 2. Please tell us where you live:

City/Town:

State:

ZIP:

Question Title

* 3. Which age group are you?

Under 65 years old

65 years old or over

Question Title

* 4. Please describe your condition/disability:

Question Title

* 5. What type of insurance do you have?

Medicare

Medicaid

Private Insurance

Other (please specify)

Question Title

* 6. What type of wheelchair do you use?

Manual wheelchair

Power wheelchair

Question Title

* 1. Please provide the following information:

Question Title

* 2. Please tell us where you live:

Question Title

* 3. Which age group are you?

Question Title

* 4. Please describe your condition/disability:

Question Title

* 5. What type of insurance do you have?

Question Title

* 6. What type of wheelchair do you use?

Question Title

* 7. How many years have you used a wheelchair?