Wheelchair Medical Necessity And Home Evaluation Verification Form

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Wheelchair Medical Necessity and Home Evaluation Verification
For Manual Wheelchair (MWC) and POVs (i.e., Power Wheelchair, Scooter, Other Power-operated Vehicle)
See Medical Policy DME101.010, Wheelchairs and Accessories
Contact person: _______________________________________Phone # _________________________
(please print)
Physical Therapist______________________________________Fax # ___________________________
Group # ____________________Patient Name_______________________________________________
Subscriber # _________________Subscriber Name____________________________________________
Referral # __________________Address ____________________________________________________
(if applicable)
(street)
______________________________________________________________________________
(city)
(state)
(zip)
Please complete all the questions fully. Failure to do so will result in delay or possible
denial of claims.
Patient Age ____________
Sex:
Male
Female
Height____________
Weight _____________
Primary Diagnosis _____________________________________Date_____________Duration?________
Secondary Diagnosis ___________________________________Date ____________Duration?________
Date you examined the patient and attested to the letter of medical necessity ________________________
What are the change(s) in your patient’s medical condition that now impairs his/her mobility?
_____________________________________________________________________________________
_____________________________________________________________________________________
Until now, what has been your patient’s mode of mobility in the home? _____________________________
_____________________________________________________________________________________
Is the patient able to safely operate a MWC? _________________________________________________
If NOT, why not? _______________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Is the patient able to safely operate and control a POV? _________________________________________
Location where MWC or POV will primarily be used? ___________________________________________
Is the patient’s duration of need greater than 6 months? _________________________________________
Can the patient safely transfer in and out of a POV? ____________________________________________
Does the patient have adequate trunk control to safely ride in a POV? _____________________________
List activities for which equipment is primarily to be used: _______________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Blue Cross Blue Shield of Illinois is a Division of Health Care Service Corporation,, a Mutual Legal Reserve Company,
1
An Independent Licensee of the Blue Cross and Blue Shield Association

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