No More Crutches!

Click here to go to our E-Reservations Page to reserve your Crutch Substitute today!

Contact Us


LTC Wheelchairs
5200 W. 78th Street
Bloomington, MN 55435


Phone: 952-941-6800

Fax: 952-941-6006




Monday-Friday: 8:30 am - 4:30 pm

Saturday & Sunday: Closed


Or use our contact form.


Privacy Practices of LTC Wheelchairs

LTC is once again proud to have passed the Accreditation by the HQAA!
LTC Wheelchairs, Wheel Chairs, Bloomington, MN

Blue Cross Blue Shield - Appointment of Rep.

Blue Cross Blue Shield - A.O.R.
Appointment of Representative form required for Blue Cross Blue Shield prior authorizations and a sample of how form needs to be completed
Blue Cross Blue Shield - AOR.pdf
Adobe Acrobat document [1.5 MB]

Crutch Substitute (E0118) "Rollabout"

Prescription form for Insurance Billing of Rollabout
Rollabout Form 2018.pdf
Adobe Acrobat document [87.9 KB]

Documentation of Face-to-Face Encounter

Required form as of October 1, 2013 for Walkers & Wheelchairs
A new requirement for Medicare and Medicare Advantage Plans for your physician
IMG Face to Face.pdf
Adobe Acrobat document [261.8 KB]

Health Partners - DME Medical Review Form

Form for Wheelchairs, Power Chairs & POV Scooters
This form is to be completed by a Health Professional and then faxed to 952-941-6006 or mailed to LTC Wheelchairs
Health Partners New 2015 Form.pdf
Adobe Acrobat document [115.5 KB]

Manual Wheelchairs

Effective - Sept. 2013 - Manual Wheelchair Prescription
Adobe Acrobat document [2.4 MB]

Medical Assistance - Mobility Device Auth Form

Medical Assistance (MHCP) - Mobility Device Auth Form
Use this form in addition to the MN-IT'S Request transaction or the Authorization Form (DHS-4695) to request authorization for a mobility device.
Medical Assistance Mobility Device Auth [...]
Adobe Acrobat document [286.3 KB]

Power Chairs

Effective - Sept. 2013 - Power Chair Prescription Form
Form to completed by Physician for Power Chairs
Adobe Acrobat document [961.7 KB]
7 Elements Order
7 Elements order (1).pdf
Adobe Acrobat document [54.9 KB]

POV - Powered Scooters

Effective - Sept. 2013 - POV - Powered Scooter Prescription
Adobe Acrobat document [734.7 KB]