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!

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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 PDF.pdf
Adobe Acrobat document [114.2 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]