How To Fill Out A Worker's Compensation Knee Scooter Claim For A Foot Or Ankle Injury

The Texas Department of Insurance that monitors

Worker's Compensation Insurance Carriers and Claims requires a H.I.C.F. (Health Insurance Claim Form) to process a knee scooter or knee walker claim. Below is a detailed list of the information needed to process a claim. Some of the information needed can be researched by a Knee Coaster advisor at 817-798-7817 or you can click here for the form.

Personal Information

Name

Your first and last name

Birth Date - mm dd yy

ex. 11 12 73

Address

Your mailing address

Phone

Your phone number where you can be reached

Physician Information

Physician Name

Your attending physician's first and last name

Physician Address

Your physician's mailing address

Physician Phone #

Your physician's phone number

Physician N.P.I. #

The N.P.I. (National Provider Identifier) number is a unique 10-digit identification number issued to covered health care providers by the CMS (Centers for Medicare and Medicaid Services)

This information can be researched by a Knee Coaster advisor at 817-798-7817

Injury Information

Diagnosis Code

ex. S92.354A Diagnosis or Nature of Injury

This information can be located on the prescription

This information can be researched by a Knee Coaster advisor at 817-798-7817

Date of Injury

The original date of injury

Insurance Information

Primary Insurance Carrier Name

The name of your worker's compensation insurance carrier

Policy ID #

Your claim # provided by your worker's compensation insurance carrier

Adjuster Name

The name of your assigned adjuster form your insurance carrier

Phone

Your adjuster's phone number where they can be reached

Fax

Your adjuster's fax number where they can be reached

Claims Mailing Address

The mailing address for submission.

This info can be researched by your Knee Coaster advisor at 817-798-7817

Secondary Insurance - If applicable

The name, phone #, address of your secondary insurance

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