Medical Insurance Claim Portal | FOLD & GO Electric Wheelchairs®

Patients ONLY Must Fill Out Their Own Insurance Information - Individuals Consent is Required

CALL your Insurance Provider and Ask the Following Questions!

Ask if your policy coverage needs a “Prior Authorization” BEFORE a claim is submitted.
The Medical Billing Code (CPT/HCPCS) for our wheelchair is K0012.
Ask what their coverage amount will be according to your policy. Then you will know exactly how much you will need to pay out-of-pocket.

1. GET A SCRIPT from your Medical Doctor. This script should have the following information:

The Script should be written to cover a “Portable Electric Wheelchair“.
Include all your Medical Diagnosis Codes (alphanumeric codes only).
Include your Doctor’s Contact Information.

2. GET A LETTER OF MEDICAL NECESSITY from your Medical Doctor.

FILL OUT the Insurance Claim Form below AFTER you have completed Steps 1 & 2!

We DO NOT hold partial claim information.
We DO NOT accept fax copies with your medical information.
Insurance companies process all claims electronically.
Your claim will NOT be submitted with partial information

MEDICAL INSURANCE CLAIMS CAN TAKE UP TO 10 MONTHS BEFORE YOU RECEIVE YOUR CHAIR

FILL OUT THE MEDICAL INSURANCE FORM ONLY AFTER YOU COMPLETE STEPS 1 & 2

FILL OUT THE MEDICAL INSURANCE FORM BELOW

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

Call Us: 512-817-FOLD (3653)

Patients ONLY Must Fill Out Their Own Insurance Information - Individuals Consent is Required

CALL your Insurance Provider and Ask the Following Questions!

1. GET A SCRIPT from your Medical Doctor. This script should have the following information:

2. GET A LETTER OF MEDICAL NECESSITY from your Medical Doctor.

FILL OUT the Insurance Claim Form below AFTER you have completed Steps 1 & 2!

MEDICAL INSURANCE CLAIMS CAN TAKE UP TO 10 MONTHS BEFORE YOU RECEIVE YOUR CHAIR

FILL OUT THE MEDICAL INSURANCE FORM ONLY AFTER YOU COMPLETE STEPS 1 & 2

FILL OUT THE MEDICAL INSURANCE FORM BELOW

INSURANCE Claim

Insurance Provider Information

Referring Doctor's Information

Model of Your Wheelchair

We DO NOT use Local Dealers or Third Parties to Handle Medical Insurance Claims - We Bill Direct!

Medical Insurance Claim EDI Portal

Patients ONLY Must Fill Out Their Own Insurance Information - Individuals Consent is Required

CALL your Insurance Provider and Ask the Following Questions!

1. GET A SCRIPT from your Medical Doctor. This script should have the following information:

2. GET A LETTER OF MEDICAL NECESSITY from your Medical Doctor.

FILL OUT the Insurance Claim Form below AFTER you have completed Steps 1 & 2!

MEDICAL INSURANCE CLAIMS CAN TAKE UP TO 10 MONTHS BEFORE YOU RECEIVE YOUR CHAIR

FILL OUT THE MEDICAL INSURANCE FORM ONLY AFTER YOU COMPLETE STEPS 1 & 2

FILL OUT THE MEDICAL INSURANCE FORM BELOW

INSURANCE Claim

Insurance Provider Information

Referring Doctor's Information

Model of Your Wheelchair

We DO NOT use Local Dealers or Third Parties to Handle Medical Insurance Claims - We Bill Direct!