Justification of Medical Necessity for Seating/Wheeled Mobility Instructions · Please print or type all information. · You must return this form to the local customer service office and accompany all wheeled mobility requests. · Complete Section I and Section V for standard wheelchair justification. · Complete Section I through Section V for specially sized or constructed wheelchair, wheelchair with custom molded seating or specially adaptive positioning devices, power wheelchair and three-wheeled vehicle justification. Injured worker's name Diagnosis, include description and ICD-9 code Section I - General Information Prognosis Claim number Type of present wheelchair Describe the problem with the present equipment: Age of wheelchair Describe the equipment that is being requested there: Describe the three most important facts this reviewer should be aware of: 1. 2. 3. Are there any medical conditions which are unrelated to the allowed injury? Yes No If yes, please describe: Cardio-respiratory status: Section II - Medical/Physical/Functional Status Tone/movement: Orthopedic considerations: Cognitive level: Visual/perceptual deficits: Weight: Sitting posture: Pelvic tilt: Leg position: Thoracic Kyphosis: Head position: Susceptible to decubitus ulcers Sensation: Present/history of ulcers: Location ischial tuberosity: Location trochanter: Wheelchair dependent Yes Yes No Skin Condition/Integrity If yes, explain Clinical Observations Height: Balance: Pelvic obliquity: Lumbar lordosis: Scoliosis: Shoulder/scapula position: No If yes, explain Bowel/bladder status: Location coccyx: Location spinous process: Time spent per day in W/C: BWC-1317 (Rev. 11/4/1997) C-190 American LegalNet, Inc. www.FormsWorkFlow.com Section II - Medical/Physical/Functional Status - Continued Upper extremity function ROM limitations Muscle strength limitations ADL status Lower extremity function Transfers Ability to perform pressure relief Wheelchair accessibility of residence Method of wheelchair transportation Wheelchair propulsion Functional Status Is there other related equipment to be evaluated or considered Section III - Equipment Justification Yes No If yes, explain Therapeutic objectives/benefits of prescribed equipment: Other special considerations: Length of time wheelchair will be needed: Mobility base: Section IV - Equipment Prescription Seating/positioning components: Notes: Evaluator's signature Name (please print) Address Section V - Evaluator Credentials Physician Phone ( ) State L.P.T. O.T. L/R License No. FAX ( ) 9 digit ZIP Code American LegalNet, Inc. www.FormsWorkFlow.com