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  • Medicare Wheelchair Evaluation Template

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Seating/Mobility Evaluation To be completed by Physiatrist or Physical/Occupational Therapist In Association With Mobility Device Specialist PATIENT INFORMATION: Name: DOB: Sex: Address: Evaluation.

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Related content

PMD Documentation Requirements (Nationwide) | CMS
Nov 14, 2019 — Power wheelchairs and power operated vehicles (also known POVs or ... A...
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Seating/Mobility Evaluation
Explain: If a manual wheelchair is recommended, does the user have sufficient...
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Jun 30, 2016 — All dates reported on the RSA-911 must be in the format ... or...
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Qualifying Diagnoses for Wheelchairs Multiple Sclerosis (MS) ALS (AKA Lou Gehrig's Disease) Parkinson's Disease. Spinal Cord Injuries. Cerebral Palsy. Muscular Dystrophy. CVA (AKA stroke-related paralysis) Post-Polio Syndrome.

One of the most common disabilities that require a wheelchair is spinal cord injuries. Injuries to the spinal cord lead to different types of impairment depending on the area of the spine that has been injured.

What happens at the assessment? The clinician will introduce themselves and explain what will happen. They will need to ask you many questions and take your measurements. They may need to assess your range of movements and physical constraints, and may ask you to demonstrate your abilities.

Answer State that your client can't stand or ambulate with any assistive device. State that your client is unable to use a lesser cost manual chair because. The client can't propel a manual wheelchair, because... if you're are advocating a power wheelchair, document why the client is unable to use a scooter because...

These include but are not limited to amputation, paralysis, cerebral palsy, stroke, multiple sclerosis, muscular dystrophy, arthritis, and spinal cord injury.

Typically the clinician is an Occupational Therapist (OT) or Physical Therapist (PT), so the prescription from your doctor will read, "OT or PT Wheelchair Evaluation." Getting a prescription from your doctor is essential, because it allows a therapist (OT or PT) to conduct an evaluation.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232