Medical Reimbursement

Follow these 3-Steps to Ensure Your Reimbursement Claim Does Not Get Denied

CALL your Insurance Provider and Ask the Following Questions!

Ask if your policy coverage needs a “Prior Authorization” BEFORE you purchase.
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.
Ask what the time frame is for your medical receipt submission.

PURCHASE your FOLD & GO WHEELCHAIR® in the Model and Color of your Choice.

WE WILL ship out your chair NEXT BUSINESS DAY.
Once the chair arrives, make sure the chair works for your needs and you do not want to return it.
FILL OUT the Medical Reimbursement Form Below.

AFTER you have Completed Steps 1 & 2!

WE WILL email you the paperwork to submit to your Insurance.
SUBMIT the Medical Reimbursement Paperwork to your Insurance Provider.
Your Insurance Provider will process the Reimbursement according to your policy coverage.
Your Insurance Provider will mail the Reimbursement check directly to you.

REIMBURSEMENT TAKES 7 to 10 DAYS to GET PAYMENT FROM YOUR INSURANCE

YOU MUST COMPLETE STEP 2 BEFORE FILLING OUT THE MEDICAL REIMBURSEMENT FORM BELOW

FILL OUT THE MEDICAL REIMBURSEMENT FORM BELOW

MEDICAL Reimbursement

Please complete the form below to assist us in creating your Medical Reimbursement for your insurance provider. We will create the Medical Reimbursement Paperwork for you. Then you will submit that paperwork after you purchase to your Insurance. We will also EDI (electronically batch) our side of that paperwork to your Insurance. Once your Insurance has both sides of the paperwork, they will send you a reimbursement check within 7-10 days.

PATIENT NAME: (required)*
First Middle Last
ADDRESS: (required)*
Street Address Address Line 2 City State ZIP Code
PHONE NUMBER: (required)*
(###) ###-####
EMAIL ADDRESS: (required)*
Enter Email Confirm Email
DATE OF BIRTH: (required)*
MM slash DD slash YYYY
INSURANCE PROVIDER: (required)*
MEMBER ID: (required)*
GROUP #: (required)*
PRIOR AUTHORIZATION NUMBER:
Many insurance providers require prior authorization for a portable electric wheelchair. Call your provider to see if your policy requires prior authorization.
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.
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, pdf, 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, pdf, Max. file size: 300 MB.
Special Notes:
If you have any unique instructions for us, please let us know.
FOLD & GO ORDER #: (required)*
Medical Reimbursement Requires a Purchase FIRST. If you have not yet purchased your FOLD & GO, then we cannot get your Insurance to Reimburse you.
WE DO NOT INFLATE THE PRICE OF OUR WHEELCHAIRS FOR INSURANCE*
FOLD & GO WHEELCHAIRS® creates a Medical Reimbursement Invoice 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 create your invoice, and we don’t have contracted discounted pricing with ANY insurance provider. Whether our customers pay by cash, credit card or their DME insurance provider, the purchase price is the same for everyone!
- I AGREED & UNDERSTAND
RETURN POLICY & MEDICAL REIMBURSEMENT*
Please make sure you have decided to keep your FOLD & GO before you submit this form for Medical Reimbursement. Once we email you the Medical Reimbursement Paperwork we CANNOT return, refund, or exchange your order. Your Insurance Provider views this action as FRAUD. Trying to receive payment for a wheelchair that has already been refunded.
- I AGREED & 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 AGREED & UNDERSTAND