D9160 - Request for Trial of Equipment (Exercise Bike/Knee Scooter) - 3 Months Only
This form is used for requesting three month trials of the following Rehabilitation Appliances Program (RAP) equipment:
- AP31 - Knee Walker and Scooter Trial
- AV18 - Stationary Exercise Bike Trial
If you are using an Apple computer and want to fill out your form electronically, please download the form and open it with Acrobat 7 or later.