Fa-1d Wheelchair Repair Form Hewlett Packard Enterprise
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2Hewlett Packard Enterprise - Nevada Medicaid and Nevada Check Up
Wheelchair Repair Form
Submit this form with FA-1 (Durable Medical Equipment Prior Authorization Request) or attach with the request
made using the Provider Web Portal.
Medical documentation by the prescribing practitioner must be submitted to support that the recipient has
ongoing medical necessity for the item needing repair. This Wheelchair Repair Form must be filled out
completely or it and the prior authorization request will be pended for more information and/or denied. A
manufacturer’s invoice for any replacement parts may be required to substantiate payment by Medicaid. DME
providers are required to educate the recipients on the proper use of durable medical equipment. Per Nevada
Medicaid policy, intentional utilization of DME in a manner not prescribed or recommended, such as an
excessive form of transportation, may be reason for denial of equipment replacement.
Fax this request to: (866) 480-9903
For questions regarding this form, call: (800) 525-2395
DATE OF REQUEST:
______ /______ /________
RECIPIENT INFORMATION
Recipient Name (Last, First, MI):
Recipient Medicaid ID:
Date of Birth:
Phone:
PROVIDER INFORMATION
Name of DME company:
NPI:
Fax:
Phone:
WHEELCHAIR INFORMATION
1. Make:________________________ Model:___________________ Serial #:______________________
2. Hour reading #:____________ Age of Equipment in months:_____ Initial Dispense Date:_____________
3. Is the wheelchair within Manufacturer’s Warranty?
Yes
No
Please submit a copy of the warranty information.
4. Name of manufacturer of replacement parts: ________________________________________________
5. What was the initial complaint from the recipient that prompted the repair evaluation?
6. How did the wheelchair come into disrepair? (If normal wear and tear please explain in complete detail the
normal daily/weekly schedule of recipient’s use of this equipment.)
FA-1D
Page 1 of 2
12/01/2015
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Parent category: Medical