We accept over 450+ health insurance providers!

Fill out the Medical Insurance Claim Form below with your information. You will upload a copy of the front and back of your insurance card, plus your doctor’s script. Insurance providers require a Doctor’s prescription for “Portable Electric Wheelchair”. Make sure your doctor puts your “Diagnosis Code or DX” on the script.

After you submit your insurance claim form, you will receive an email confirmation from us recapping the information you submitted. We submit your claim electronically (EDI) to your insurance on the same day you submit it.  Most insurance companies acknowledge receipt of the claim within 48 hours. If your insurance company needs any additional information to process your claim, we will contact you.

Now we WAIT ON YOUR INSURANCE COMPANY to decide to approve your claim and tell us how much of your FOLD & GO WHEELCHAIR they are going to pay for. We will contact you immediately with their decision and payment information.

While we are waiting for the insurance payment to arrive, we will collect any remaining balance from you. Once your chair is paid in full, it will ship out that same business day.

FILL IN THE MEDICAL INSURANCE CLAIM FORM BELOW

Medical Insurance Claim

Please complete the form below to have your wheelchair purchase submitted to your insurance for payment. 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. In our pursuit of this passion, we have done all the legwork so we can accept insurance billing. We now have a state of the art billing software program, so we can submit your claim directly to your provider.
  • (###-##-####)
  • Click to Highlight all that Apply
  • Most insurance providers require prior authorization before the claim is submitted. Please put that number here.
  • If the policy is not listed in your name, please provider the policy holder's name here.
  • 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.
  • 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.
  • Insurance providers require a Doctor's prescription for "Portable Electric Wheelchair" so please upload a copy of that script here. Make sure your doctor puts your "Diagnosis Code or DX" on the script.
    Drop files here or
    Accepted file types: jpg, gif, png, pdf, bmp, tiff, doc, docx.
  • Select the size and color for the wheelchair you want
  • If you have any unique instructions for us, please let us know.
  • FOLD & GO WHEEELCHAIRS® submits insurance claim amounts for our folding electric wheelchairs (K0012) as per the advertised purchase price listed on our website. We do not inflate the purchase price of our wheelchairs when we bill your insurance provider, and we don’t have contracted discounted pricing with ANY insurance provider. Whether our customers pay by cash, credit card, PayPal or their DME insurance provider, the purchase price is the same for everyone!

HIPAA

Compliance with our state and federal partners is essential to providing accurate, timely and comprehensive care to our customers. Protected Health Information (PHI) under HIPAA’s Privacy Rule provides federal protections for personal health information held by covered entities and gives patients an array of rights with respect to that information.

For complete description of physician/provider requirements, visit the Department of Health & Human Services website at: http://www.hhs.gov/ocr/privacy/hipaa/understanding/coveredentities/index.html

National Provider Identifier (NPI)

The National Provider Identifier (NPI) is a Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Standard. An NPI is a unique identification number for covered health care providers and is mandated by HIPAA on all (electronically) filed claims.