Insurance Forms - Comfort Care

Comfort Care provides this form to help customers organize reimbursement information for their insurance plan. Coverage, documentation requirements, and reimbursement decisions are determined by the customer's insurance company, Medicare plan, or benefits administrator.

Mobility Equipment Reimbursement Request Form

Use this worksheet when submitting rental or purchase information to an insurance plan, health savings account, flexible spending account, or reimbursement administrator.

Customer Information

Customer name

Date of birth

Phone number

Email address

Delivery address

Insurance Information

Insurance company / plan

Member ID

Group number

Claims phone / website

Policyholder name, if different

Equipment Information

Hospital bed Wheelchair Walker Rollator Knee scooter Bed rails / accessories Mattress / overlay Other equipment

Rental start date

Rental end date / monthly rental

Total paid

Receipt / order number

Equipment notes

Documents to Attach

Comfort Care receipt or invoice Payment confirmation Insurance claim form, if required by plan Doctor order or medical necessity document, if required Delivery confirmation, if requested Any plan-specific reimbursement paperwork

Customer Authorization

I understand this form is for reimbursement organization only and does not guarantee insurance payment. I am responsible for submitting required documentation to my insurance plan or reimbursement administrator.

Customer signature

Date