Get Specialized Services Customized Manual Wheelchair (cmwc) Authorization Request - Dads State Tx

This guide provides step-by-step instructions for completing the Specialized Services Customized Manual Wheelchair (CMWC) Authorization Request online. It aims to simplify the process for anyone seeking to submit this important request.

Follow the steps to effectively complete your CMWC authorization request.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred online editor.
2. Fill in today's date at the top of the form. This is essential for tracking the submission timeline.
3. In the 'To' section, direct the submission to the DADS Access and Intake PASRR Unit, ensuring to note the fax number 512-438-2180.
4. Complete the 'From' section with the name, title, and contact information of the nursing facility representative.
5. Indicate if this submission includes a transfer request for the authorization of a CMWC to a new facility. If 'Yes', only Sections A, E, and F require completion.
6. In Section A, provide identifying information about the resident and nursing facility. Fill in the resident's name, Medicaid number, date of birth, and whether the resident is age 21 or older.
7. Include the information of the resident’s legally authorized representative (LAR), as necessary.
8. In Section B, provide therapist identifying information and CMWC assessment details, including muscle tone, postural control, and medical history.
9. Continue through the CMWC assessment, addressing each component regarding the resident’s physical limitations, medical history, and expected changes.
10. Section C requires details of the supplier and a list of itemized MSRP quotes for the wheelchair and related items required.
11. Complete Section D with the physician-related information, including diagnosis, functionality statement, and physician’s attestation of medical necessity.
12. If applicable, fill out Section E for transfer requests including the medical professional’s certification.
13. In Section F, ensure the nursing facility administrator acknowledges the request by signing and dating the form.
14. Finally, review the form for completeness and accuracy. Save changes, download, or print the completed form for submission.

Complete your CMWC authorization request online today to ensure timely processing and support.