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: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming 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 * 7. How many years have you used a wheelchair? Next