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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