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.

1.Please provide the following information:(Required.)

Name:

Email Address:

Phone Number:

2.Please tell us where you live:(Required.)

City/Town:

State:

ZIP:

3.Which age group are you?(Required.)

Under 65 years old

65 years old or over

4.Please describe your condition/disability:

5.What type of insurance do you have? (Required.)

Medicare

Medicaid

Private Insurance

Other (please specify)

6.What type of wheelchair do you use? (Required.)

Manual wheelchair

Power wheelchair

7.How many years have you used a wheelchair?