{"id":1705,"date":"2022-04-28T13:43:35","date_gmt":"2022-04-28T13:43:35","guid":{"rendered":"https:\/\/shop.arpwave.com\/clone-of-service-request-form\/"},"modified":"2024-10-02T08:31:44","modified_gmt":"2024-10-02T13:31:44","slug":"determination-of-benefits-check","status":"publish","type":"page","link":"https:\/\/arpwave.com\/shop\/determination-of-benefits-check\/","title":{"rendered":"Determination of Benefits Check"},"content":{"rendered":"<p>For any questions, please contact ARPwave via phone at (952)431-9708 or via email at info@arpwave.com<\/p>\n<style id=\"wpforms-css-vars-1583\">\n\t\t\t\t#wpforms-1583 {\n\t\t\t\t\n\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-render-modern\" id=\"wpforms-1583\"><form id=\"wpforms-form-1583\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"1583\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/shop\/wp-json\/wp\/v2\/pages\/1705\" data-token=\"d58a34fb8ce05e48882edb82e98f3f65\" data-token-time=\"1777728737\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-1583-field_3-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-1583-field_3\">Date (mm-dd-yyyy)<\/label><input type=\"text\" id=\"wpforms-1583-field_3\" class=\"wpforms-field-medium\" name=\"wpforms[fields][3]\" aria-errormessage=\"wpforms-1583-field_3-error\" ><\/div><div id=\"wpforms-1583-field_16-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"16\"><label class=\"wpforms-field-label\" for=\"wpforms-1583-field_16\">Unit Type<\/label><select id=\"wpforms-1583-field_16\" class=\"wpforms-field-medium\" name=\"wpforms[fields][16]\"><option value=\"Select One\"  class=\"choice-4 depth-1\"  >Select One<\/option><option value=\"Rx100\"  class=\"choice-1 depth-1\"  >Rx100<\/option><option value=\"PovSport\"  class=\"choice-5 depth-1\"  >PovSport<\/option><option value=\"ARPtrainer\"  class=\"choice-2 depth-1\"  >ARPtrainer<\/option><option value=\"FlexDoctor\/PRS\"  class=\"choice-3 depth-1\"  >FlexDoctor\/PRS<\/option><\/select><\/div><div id=\"wpforms-1583-field_4-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-1583-field_4\">Clinic or Therapist Name (If Applicable)<\/label><input type=\"text\" id=\"wpforms-1583-field_4\" class=\"wpforms-field-medium\" name=\"wpforms[fields][4]\" aria-errormessage=\"wpforms-1583-field_4-error\" ><\/div><div id=\"wpforms-1583-field_0-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"0\"><fieldset><legend class=\"wpforms-field-label\">Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-1583-field_0\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][0][first]\" aria-errormessage=\"wpforms-1583-field_0-error\" required><label for=\"wpforms-1583-field_0\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-1583-field_0-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][0][last]\" aria-errormessage=\"wpforms-1583-field_0-last-error\" required><label for=\"wpforms-1583-field_0-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-1583-field_1-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-1583-field_1\">Email <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-1583-field_1\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][1]\" spellcheck=\"false\" aria-errormessage=\"wpforms-1583-field_1-error\" required><\/div><div id=\"wpforms-1583-field_19-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"19\"><label class=\"wpforms-field-label\" for=\"wpforms-1583-field_19\">Phone <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1583-field_19\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][19]\" aria-errormessage=\"wpforms-1583-field_19-error\" required><\/div><div id=\"wpforms-1583-field_7-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"7\"><label class=\"wpforms-field-label\" for=\"wpforms-1583-field_7\">Street Address <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1583-field_7\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][7]\" aria-errormessage=\"wpforms-1583-field_7-error\" required><\/div><div id=\"wpforms-1583-field_8-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"8\"><label class=\"wpforms-field-label\" for=\"wpforms-1583-field_8\">City <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1583-field_8\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][8]\" aria-errormessage=\"wpforms-1583-field_8-error\" required><\/div><div id=\"wpforms-1583-field_10-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-1583-field_10\">State <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-1583-field_10\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][10]\" required=\"required\"><option value=\"Select State\"  class=\"choice-55 depth-1\"  >Select State<\/option><option value=\"Alabama - AL\"  class=\"choice-4 depth-1\"  >Alabama - AL<\/option><option value=\"Alaska - AK\"  class=\"choice-5 depth-1\"  >Alaska - AK<\/option><option value=\"Arizona - AZ\"  class=\"choice-6 depth-1\"  >Arizona - AZ<\/option><option value=\"Arkansas - AR\"  class=\"choice-7 depth-1\"  >Arkansas - AR<\/option><option value=\"California - CA\"  class=\"choice-8 depth-1\"  >California - CA<\/option><option value=\"Colorado\t- CO\"  class=\"choice-9 depth-1\"  >Colorado\t- CO<\/option><option value=\"Connecticut\t- CT\"  class=\"choice-10 depth-1\"  >Connecticut\t- CT<\/option><option value=\"Delaware - DE\"  class=\"choice-11 depth-1\"  >Delaware - DE<\/option><option value=\"Florida - FL\"  class=\"choice-12 depth-1\"  >Florida - FL<\/option><option value=\"Georgia - GA\"  class=\"choice-13 depth-1\"  >Georgia - GA<\/option><option value=\"Hawaii - HI\"  class=\"choice-14 depth-1\"  >Hawaii - HI<\/option><option value=\"Idaho - ID\"  class=\"choice-15 depth-1\"  >Idaho - ID<\/option><option value=\"Illinois - IL\"  class=\"choice-16 depth-1\"  >Illinois - IL<\/option><option value=\"Indiana - IN\"  class=\"choice-17 depth-1\"  >Indiana - IN<\/option><option value=\"Iowa - IA\"  class=\"choice-18 depth-1\"  >Iowa - IA<\/option><option value=\"Kansas - KS\"  class=\"choice-19 depth-1\"  >Kansas - KS<\/option><option value=\"Kentucky - KY\"  class=\"choice-20 depth-1\"  >Kentucky - KY<\/option><option value=\"Louisiana - LA\"  class=\"choice-21 depth-1\"  >Louisiana - LA<\/option><option value=\"Maine - ME\"  class=\"choice-22 depth-1\"  >Maine - ME<\/option><option value=\"Maryland - MD\"  class=\"choice-23 depth-1\"  >Maryland - MD<\/option><option value=\"Massachusetts - MA\"  class=\"choice-24 depth-1\"  >Massachusetts - MA<\/option><option value=\"Michigan - MI\"  class=\"choice-25 depth-1\"  >Michigan - MI<\/option><option value=\"Minnesota - MN\"  class=\"choice-26 depth-1\"  >Minnesota - MN<\/option><option value=\"Mississippi - MS\"  class=\"choice-27 depth-1\"  >Mississippi - MS<\/option><option value=\"Missouri - MO\"  class=\"choice-28 depth-1\"  >Missouri - MO<\/option><option value=\"Montana - MT\"  class=\"choice-29 depth-1\"  >Montana - MT<\/option><option value=\"Nebraska\t- NE\"  class=\"choice-30 depth-1\"  >Nebraska\t- NE<\/option><option value=\"Nevada - NV\"  class=\"choice-31 depth-1\"  >Nevada - NV<\/option><option value=\"New Hampshire - NH\"  class=\"choice-32 depth-1\"  >New Hampshire - NH<\/option><option value=\"New Jersey - NJ\"  class=\"choice-33 depth-1\"  >New Jersey - NJ<\/option><option value=\"New Mexico - NM\"  class=\"choice-34 depth-1\"  >New Mexico - NM<\/option><option value=\"New York - NY\"  class=\"choice-35 depth-1\"  >New York - NY<\/option><option value=\"North Carolina - NC\"  class=\"choice-36 depth-1\"  >North Carolina - NC<\/option><option value=\"North Dakota - ND\"  class=\"choice-37 depth-1\"  >North Dakota - ND<\/option><option value=\"Ohio - OH\"  class=\"choice-38 depth-1\"  >Ohio - OH<\/option><option value=\"Oklahoma - OK\"  class=\"choice-39 depth-1\"  >Oklahoma - OK<\/option><option value=\"Oregon - OR\"  class=\"choice-40 depth-1\"  >Oregon - OR<\/option><option value=\"Pennsylvania - PA\"  class=\"choice-41 depth-1\"  >Pennsylvania - PA<\/option><option value=\"Rhode Island - RI\"  class=\"choice-42 depth-1\"  >Rhode Island - RI<\/option><option value=\"South Carolina - SC\"  class=\"choice-43 depth-1\"  >South Carolina - SC<\/option><option value=\"South Dakota - SD\"  class=\"choice-44 depth-1\"  >South Dakota - SD<\/option><option value=\"Tennessee - TN\"  class=\"choice-45 depth-1\"  >Tennessee - TN<\/option><option value=\"Texas - TX\"  class=\"choice-46 depth-1\"  >Texas - TX<\/option><option value=\"Utah - UT\"  class=\"choice-47 depth-1\"  >Utah - UT<\/option><option value=\"Vermont - VT\"  class=\"choice-48 depth-1\"  >Vermont - VT<\/option><option value=\"Virginia - VA\"  class=\"choice-49 depth-1\"  >Virginia - VA<\/option><option value=\"Washington - WA\"  class=\"choice-50 depth-1\"  >Washington - WA<\/option><option value=\"West Virginia - WV\"  class=\"choice-51 depth-1\"  >West Virginia - WV<\/option><option value=\"Wisconsin - WI\"  class=\"choice-52 depth-1\"  >Wisconsin - WI<\/option><option value=\"Wyoming - WY\"  class=\"choice-53 depth-1\"  >Wyoming - WY<\/option><option value=\"Outside the USA\"  class=\"choice-54 depth-1\"  >Outside the USA<\/option><\/select><\/div><div id=\"wpforms-1583-field_11-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-1583-field_11\">Zip Code <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1583-field_11\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][11]\" aria-errormessage=\"wpforms-1583-field_11-error\" required><\/div><div id=\"wpforms-1583-field_9-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-1583-field_9\">Country (If outside the USA)<\/label><input type=\"text\" id=\"wpforms-1583-field_9\" class=\"wpforms-field-medium\" name=\"wpforms[fields][9]\" aria-errormessage=\"wpforms-1583-field_9-error\" ><\/div><div id=\"wpforms-1583-field_12-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-1583-field_12\">Unit Serial Number <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1583-field_12\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][12]\" aria-errormessage=\"wpforms-1583-field_12-error\" required><\/div><div id=\"wpforms-1583-field_17-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"17\"><label class=\"wpforms-field-label\" for=\"wpforms-1583-field_17\">Credits Remaining (If Applicable)<\/label><input type=\"text\" id=\"wpforms-1583-field_17\" class=\"wpforms-field-medium\" name=\"wpforms[fields][17]\" aria-errormessage=\"wpforms-1583-field_17-error\" ><\/div><div id=\"wpforms-1583-field_28-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"28\"><label class=\"wpforms-field-label\" for=\"wpforms-1583-field_28\">Detailed Description of The Problem<\/label><textarea id=\"wpforms-1583-field_28\" class=\"wpforms-field-medium\" name=\"wpforms[fields][28]\" aria-errormessage=\"wpforms-1583-field_28-error\" aria-describedby=\"wpforms-1583-field_28-description\" ><\/textarea><div id=\"wpforms-1583-field_28-description\" class=\"wpforms-field-description\">If this is an issue with an accessory please contact the ARPwave office at (952)431-9708<\/div><\/div><div id=\"wpforms-1583-field_29-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"29\"><label class=\"wpforms-field-label\" for=\"wpforms-1583-field_29\">&quot;Ship To&quot; Address if Different Than Above<\/label><textarea id=\"wpforms-1583-field_29\" class=\"wpforms-field-medium\" name=\"wpforms[fields][29]\" aria-errormessage=\"wpforms-1583-field_29-error\" ><\/textarea><\/div><div id=\"wpforms-1583-field_32-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"32\"><fieldset><legend class=\"wpforms-field-label\">Loaner Requested<\/legend><ul id=\"wpforms-1583-field_32\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1583-field_32_1\" name=\"wpforms[fields][32][]\" value=\"Yes\" aria-errormessage=\"wpforms-1583-field_32_1-error\" aria-describedby=\"wpforms-1583-field_32-description\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1583-field_32_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1583-field_32_2\" name=\"wpforms[fields][32][]\" value=\"Not Interested\" aria-errormessage=\"wpforms-1583-field_32_2-error\" aria-describedby=\"wpforms-1583-field_32-description\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1583-field_32_2\">Not Interested<\/label><\/li><\/ul><div id=\"wpforms-1583-field_32-description\" class=\"wpforms-field-description\">Loaners available based upon availability.  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