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Get Fl Ayms Medicare Requires The Following Documentation For Prescribing Manual Wheelchairs

Ddress: City: State: Zip: Telephone: D.O.B. Medicare Number: Secondary Insurance: Policy Number: Phone Number: Physician Use Only Instructions for Prescribing a Manual Wheelchair 1 2 Please write a Prescription for a Manual Wheelchair. Please complete the attached Detailed Written Order for a Manual Wheelchair. Please provide chart notes that outline: 1) The patient s mobility limitations. Please show how limitations affect participation in one or more Mobility Related Activity to.

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