Wheelchair Order Form

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Prescriber Name A value is required. Phone Number A value is required.Invalid format.
Address A value is required. NPI A value is required.Invalid format.Minimum number of characters not met.Exceeded maximum number of characters.
City A value is required. Fax

Patient Name: A value is required. Phone Number: A value is required.Invalid format.
Address: Weight A value is required.Minimum number of characters not met.Exceeded maximum number of characters.(lbs)
City: Height (ft' in")
Zip: Date Of Birth A value is required.Invalid format.

Emergency Contact:

Phone Number:

Length of Need:

(Months)

Lifetime

Payment Method

Primary Insurance

ID#

Secondary Insurance

ID#:

Does Patient have a Medicare Advantage Plan?

Primary Diagnosis Supporting Need of Wheelchair

Secondary Diagnoses
1. Does the Patient have a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADL) such as: toileting, feeding, dressing, grooming, and/or bathing?
2. Can the patient's mobility limitation be sufficiently resolved by the use of an appropriately fitted cane or walker?
3. Does the patient's home provide adequate access between room, maneuvering space and surfaces for the use of the manual wheelchair provided?
4. Will the use of a manual wheelchair significantly improve this patient's ability to participate in MRADLs and will the patient use it on a regular basis in the home?
5. Is the patient willing to use it around their home?

6. Does the patient have sufficient upper body strength and other mental and physical capabilities to self propel the wheelchair around the home?

7. If No Can this be resolved with the use of a Lightweight Wheelchair

8 Does the patient have a caregiver who is available, willing and able to provide assistance with the wheelchair?