D9160 - Request for Trial of Equipment (Exercise Bike/Knee Scooter) - 3 Months Only

Form ID
D9160
Audience
For providers
Chiropractor
Exercise physiologist
General Practitioner
Medical specialist
Osteopath
Physiotherapist

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.

How can I access this form?
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Form (PDF or Word)