How to File Wheelchair and Related Claims
Using the linked form, follow these instructions when submitting Medicare claims on your own for any wheelchair or durable medical equipment related item.
Follow these instructions when completing this blank Medicare Claim Form
HOW TO FILL OUT YOUR MEDICARE CLAIM FORM
FOLLOW THESE INSTRUCTIONS CAREFULLY:
BLOCK 1: Print your name shown on your Medicare Card (Last Name, First Name, Middle Name).
BLOCK 2: Print your Medicare number including the letter(s) located either at the beginning or the end of your Medicare Number exactly as it is shown on your Medicare Card. In the same block, please check the appropriate box for Patient’s Sex.
BLOCK 3: Please provide your full mailing address.
BLOCK 3B: Please provide your telephone number including area code.
BLOCK 4: Describe the medical condition for which you are being treated.
BLOCKS 4B and 4C: Please check the appropriate boxes
BLOCK 5A: If you are 65 or older, employed, and enrolled in a health insurance plan under your employer, complete this block.
BLOCK 5B: If you are 65 or older and covered under a health insurance plan under your spouse’s employer, complete this block.
BLOCK 5C: If you have any other medical coverage other than Medicare, provide the Policy or Medical Assistance Number.
Check the box provided if you do not want payment information from this claim release to another insurer.
BLOCK 6: Be sure to sign your name. If you cannot sign your name, make an “X” mark and have a witness sign his or her name in Block 6 also. If you are completing this form for another Medicare beneficiary, you should write “By” and sign your name and provide your address in Block 6. You should also show your relationship to the beneficiary and briefly explain why the beneficiary can not sign.
BLOCK 6B: Please print the date you completed this claim form.
INFORMATION THAT SHOULD BE INCLUDED ON ITEMIZED BILL:
- Date of each service or supply received
- The location where each service or supply was received
- Description of each medical service or supply furnished
- Amount Charged for each service received
- The name & address of the company who provided the services. Their Medicare supplier number must be included.
- Mark out any services or supplies on the itemized bill which do not apply.
- If you send in a prescription for a medical supply or service, make sure the diagnosis code is listed on the prescription. Your physician will have this information.
- If you are filing this claim on behalf of a deceased beneficiary, please contact your local Social Security office for any additional information necessary to send to Medicare for processing of the claim.
- If you are covered under an insurance that pays before Medicare, attach an Explanation of Benefits from that insurance company if you are also requesting Medicare payment.
Mail the Claim Form to Medicare at the specified address on the form.