Submit the completed form with all required evaluations to the patient's insurance provider. Use the following contact details: Fax: 412-544-2921 Include typed physician face-to-face examination report, wheelchair evaluation, and home evaluation if available. Ensure all parts of the form are complete and signed by a licensed physician. Store a copy of the submitted form and supporting documents for your records. Advice: Consult with a licensed medical professional when completing this form.

Ensure the form is submitted with all evaluations dated accordingly. Update form usage dates annually based on the patient's medical condition and insurance requirements.

The purpose of the Certificate of Medical Necessity (CMN) for Motorized Wheelchairs is to assess and document a patient's need for a motorized wheelchair due to medical conditions. This form ensures that the patient meets the necessary criteria for obtaining a motorized wheelchair, including the assessment of mobility limitations, home environment suitability, and necessary evaluations by medical professionals. Completing this form accurately is essential for obtaining insurance coverage and receiving the appropriate medical equipment. This form also serves as a comprehensive record of the patient's condition and the medical justifications for the use of a motorized wheelchair, ensuring that the patient receives the best possible care and support.

• 1. Requesting Provider: Name of the provider requesting the wheelchair.
• 2. Patient Name: Name of the patient in need of the wheelchair.
• 3. ID Number: Patient's identification number.
• 4. Mobility Limitation Questions: Questions related to the patient's ability to perform daily living activities.
• 5. Home Environment: Details about the patient's home accessibility for wheelchair use.
• 6. Upper Extremities Weakness: Inquiry about the patient's upper extremity strength due to medical conditions.
• 7. Wheelchair Requirement: Confirmation of the patient's need for a wheelchair.
• 8. Mental and Physical Capabilities: Assessment of the patient's mental and physical capabilities for using a motorized wheelchair.
• 9. Coverage Criteria: Details about whether the patient meets the coverage criteria for powered seating systems.
• 10. Powered Seating Accessories: Information on the necessity of powered seating accessories for the patient.
• 11. Drive Control Interface: Details about the required drive control interface for the patient.
• 12. Independent Stand and Pivot Transfer: Confirmation of the patient's ability to independently stand and pivot transfer.
• 13. Rehabilitation Therapist Evaluation: Information about the evaluation performed by a licensed therapist.
• 14. Physician Examination Date: Date of the face-to-face physician examination.
• 15. Hours in Wheelchair: Average number of hours per day the patient spends in the wheelchair.
• 16. Contact Name: Name of the contact person for the form.
• 17. Physician Signature: Signature of the physician, mandatory for the document.
• 18. Requested Information: Additional information required for the form completion.

Failure to submit this form may result in the patient not receiving the necessary motorized wheelchair coverage or equipment.

• Insurance Coverage: Without this form, insurance may not cover the cost of the motorized wheelchair.
• Medical Equipment: The patient may not receive the necessary motorized wheelchair, affecting mobility.
• Delays in Care: Lack of proper documentation can delay the patient's access to needed medical equipment.

• 1. Patient Assessment: To evaluate if a patient qualifies for a motorized wheelchair.
• 2. Insurance Approval: To obtain insurance coverage for a motorized wheelchair.
• 3. Medical Documentation: For providing necessary medical documentation of the patient's condition.
• 4. Home Environment Assessment: To determine if the patient's home is suitable for a motorized wheelchair.
• 5. Therapist Evaluation: When a rehabilitation therapist needs to evaluate the patient's wheelchair needs.