Insurance Claim Form

Must Be Filled Out by the PATIENT ONLY - A Doctor’s office CANNOT Fill out this Form

An insurance claim is a bill that is sent electronically to your insurance by us, and once we receive payment from your insurance, plus your copayment or deductible, we will ship the product to your doorstep. Once we receive your insurance claim, please allow 5-7 business days for us to electronically submit the claim to your insurance. We will email you a copy of the claim so you can follow up directly with your insurance. We DO NOT need an Order from your Doctor.

Commercial Insurance Coverage

Medical Insurance Coverage provided through an Employer for people that are currently working. This type of Coverage may also cover your immediate family including a spouse and children.

Governmental Insurance Coverage

Insurance Coverage provided through a federally funded employer: Medicare, Medicaid, Obamacare (ACA), Federal or State Employer, Military, Police, Fire, Public Schools, and Hospitals.

CALL your Insurance Provider to Find Out Your Prerequisites:

Prescription – a script from your doctor for a Fold & Go MagSHOCK or Neudol wheelchair. It is important that the doctor is specific to our company and the chair model to help you get in-network coverage.
Letter of Medical Necessity – a letter from your doctor that states the medical reasons why the Fold & Go Wheelchair is necessary for you. Have them use the words “lightweight, foldable, made of magnesium, and weatherproof.” Being specific to the characteristics of our chairs and why these characteristics are necessary for you will help you get in-network coverage.
Prior Auth/Pre-certification – if required, it MUST be done by someone locally that medically treats you. It also must be done BEFORE you can fill out the insurance claim paperwork otherwise, your insurance will automatically deny our insurance claim and we will have to start over AFTER the prior auth/pre-certification has been done.
Your doctor will need the following information to process this request with the insurance:
1. CPT CODE: K0012
2. Our NPI: 1316489412
Verify Your Out-of-Network Benefits – If you live outside of Austin, Texas (Our Warehouse Location).
1. Don’t worry if your insurance pushes the claim out-of-network at first. As long as we have a prescription and letter of medical necessity that states the Fold & Go Wheelchair is necessary for the patient, the insurance will eventually give us in-network benefits on the claim.
2. If your policy does not include out-of-network coverage, please call our insurance department BEFORE you fill out the insurance claim paperwork.

FILL OUT the Insurance Claim Form below AFTER you have completed Steps 1!

It MUST be filled out by the patient, a family member or a friend that is assisting the patient.
A doctor’s office CANNOT fill out this paperwork:
- They cannot give us permission to work with your insurance or the doctor’s office on your behalf.
- They cannot accept financial responsibility for costs that are not covered by the insurance.
Items that are missing or not included in the Insurance Paperwork as requested, will prevent us from filing a claim to your insurance.

FILL OUT THE MEDICAL INSURANCE FORM ONLY AFTER YOU COMPLETE STEP 1

INSURANCE Claim

Please complete the form below to assist us in submitting a claim to your insurance provider. It is our passion to do whatever we can to help our customers break free from their physical prisons, and find freedom, independence, and mobility.

PATIENT NAME: (required)*
First Middle Last
DATE OF BIRTH: (required)*
MM slash DD slash YYYY
GENDER: (required)*
ADDRESS: (required)*
Street Address Address Line 2 City State ZIP Code
PHONE NUMBER: (required)*
(###) ###-####
EMAIL ADDRESS: (required)*
Enter Email Confirm Email
MARITAL STATUS: (required)*
EMPLOYED: (required)*
STUDENT: (required)*
ETHNICITY: (required)*
RACE: (required)*
SEXUAL ORIENTATION:
GENDER IDENTITY:
Insurance Provider Information
INSURANCE PROVIDER: (required)*
MEMBER ID: (required)*
GROUP #: (required)*
RELATIONSHIP TO INSURED: (required)*
POLICY HOLDER'S NAME: (required)*
Name of the person listed on the FRONT of your insurance card.
First Middle Last
POLICY HOLDER'S DATE OF BIRTH: (required)*
Birth date of the person listed on the FRONT of your insurance card.
MM slash DD slash YYYY
PRIOR AUTHORIZATION NUMBER: (required)
Many insurance providers require prior authorization for a portable electric wheelchair. Call your provider to see if your policy requires prior authorization for billing code K0012.
TYPE OF COVERAGE: (required)*
UPLOAD FRONT OF INSURANCE CARD: (required)*
Please upload an image of the FRONT of your medical insurance card.
Drop files here or
Accepted file types: jpg, gif, png, pdf, bmp, tiff, doc, docx, jpeg, Max. file size: 300 MB.
UPLOAD BACK OF INSURANCE CARD: (required)*
Please upload an image of the BACK of your medical insurance card.
Drop files here or
Accepted file types: jpg, gif, png, pdf, bmp, tiff, doc, docx, jpeg, Max. file size: 300 MB.
Referring Doctor's Information
DOCTOR'S NAME: (required)*
First Middle Last
DOCTOR'S GENDER: (required)*
DOCTOR'S ADDRESS: (required)*
Street Address Address Line 2 City State ZIP Code
DOCTOR'S PHONE: (required)*
DOCTOR'S LICENSE #: (required)*
DOCTOR'S NPI #: (required)*
DIAGNOSIS CODE(S): (required)*
List any and all alpha numeric diagnosis codes for your current disease, illness or injury. Keep in mind not all codes qualify for an electric wheelchair. CODE EXAMPLES: M19.90, S49.91, G89.29, etc.
COPY OF DOCTOR'S PRESCRIPTION: (required)*
Please upload an image of your doctor's script.
Drop files here or
Accepted file types: jpg, gif, png, pdf, bmp, tiff, doc, docx, jpeg, Max. file size: 300 MB.
Model of Your Wheelchair
MODEL OF WHEELCHAIR: (required)*
- MagSHOCK (Price $2,895)
- Neudol (Price $2,695)
Special Notes:
If you have any unique instructions for us, please let us know.
WE DO NOT INFLATE THE PRICE OF OUR WHEELCHAIRS FOR INSURANCE*
FOLD & GO WHEELCHAIRS® does not inflate the purchase price of our wheelchairs when we submit a claim to your provider. The purchase of your wheelchair is clearly listed on our website for your insurance provider to validate. Whether our customers pay by cash, credit card or their DME insurance provider, the purchase price is the same for everyone!
- I AGREE & UNDERSTAND
WE DO NOT HAVE DISCOUNT PRICING WITH INSURANCE PROVIDERS*
FOLD & GO WHEELCHAIRS® does not have contracted discounted pricing with ANY insurance provider.
- I AGREE & UNDERSTAND
YOUR WHEELCHAIR DOES NOT SHIP UNTIL THE PRICE IS PAID IN FULL*
FOLD & GO WHEELCHAIRS® does not ship your wheelchair until we have received payment from your insurance provider, and any out-of-pocket portion you may owe.
- I AGREE & UNDERSTAND
RETURN POLICY & INSURANCE CLAIMS*
FOLD & GO WHEELCHAIRS® does not allow any returns, refunds or exchanges for wheelchairs purchased by an Insurance Provider. Once your Insurance Provider pays for your chair, you cannot return it. Your Insurance Provider views this action as FRAUD.
- I AGREE & UNDERSTAND
Patient Financial Responsibility Insurance Disclaimer:*
The Patient’s health insurance company or governmental program policy determines the covered amount available due to the Patient’s policy limitations, and their medical necessity that is determined by the Patient’s Physician. Not all insurance policies are the same, and not all approvals are for the medical durable equipment that FOLD & GO WHEELCHAIRS® provides. Any medical equipment costs not covered by the Patient’s insurance are the responsibility of the Patient, and not the responsibility of FOLD & GO WHEELCHAIRS®. This includes ANY co-pays, deductibles, and non-covered portions. If any uncovered amounts are above and beyond the costs deemed allowable by any insurance or governmental standards or guidelines, the patient accepts full responsibility to cover these overages and FOLD & GO WHEELCHAIRS® cannot be held liable for these pricing differences. All FOLD & GO WHEELCHAIRS® prices are listed upfront and in full view of anyone looking at the website. All FOLD & GO WHEELCHAIRS® pricing is within the industry standards for lightweight, foldable, weatherproof, electric wheelchairs, and may not adhere to the outdated governmental or insurance standards for actual product costs.
- I AGREE & UNDERSTAND
CAPTCHA

Must Be Filled Out by the PATIENT ONLY - A Doctor’s office CANNOT Fill out this Form

Commercial Insurance Coverage

Governmental Insurance Coverage

CALL your Insurance Provider to Find Out Your Prerequisites:

FILL OUT the Insurance Claim Form below AFTER you have completed Steps 1!

FILL OUT THE MEDICAL INSURANCE FORM ONLY AFTER YOU COMPLETE STEP 1

INSURANCE Claim

Insurance Provider Information

Referring Doctor's Information

Model of Your Wheelchair

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