Washington State Medicaid Order Forms


(Dated Prior to 1-5-15)

Power Chairs (WA Only)

Jazzy 1450 SP (WA Only)

Jazzy 1650 Series (WA Only)

Jazzy 614 (WA Only)

Jazzy 614 HD (WA Only)

Z-Chair (WA Only)


Seating and Positioning (WA Only)


Electronics (WA Only)

Q-Logic Controls (WA Only)


Manual Wheelchairs (WA Only)

LiteStream Junior (WA Only)

Litestream XF (WA Only)

Stylus LS (WA Only)


Go-Go Travel Mobility (WA Only)


Pride Lifts (WA Only)