Get Home Evaluation Form

Filling out the Home Evaluation Form online is an essential step to ensure that your home can accommodate necessary mobility assistive equipment. This guide will provide clear and detailed instructions on how to navigate and complete the form effectively.

Follow the steps to complete the Home Evaluation Form online

1. Click 'Get Form' button to access the Home Evaluation Form and open it in your preferred editing tool.
2. Fill out the 'Patient Information' section by entering the name, address, phone number, and date of birth of the individual for whom the evaluation is being conducted.
3. Specify the type of mobility assistive equipment (MAE) needed by selecting from the options: Manual Chair, POV/Scooter, or Power Wheelchair.
4. Indicate the type of home by selecting one of the options: Single Story, Multi-Story, Handicap Accessible, Apt./Condo, Mobile Home, and specify if ramps, stairs, or elevators are available.
5. In the 'Equipment Trials' section, detail the make, model, and turning radius of the MAE to assist with evaluation.
6. Assess the home environment by answering if there are any physical factors that could affect the usability of the MAE in the home. Provide measurements for each room where applicable: Bathroom, Bedroom, Kitchen, Hallways, and Other rooms.
7. Complete the Supplier Attestation by confirming that an assessment of the patient’s home has been conducted and specify all applicable MAE types.
8. Finally, date the Home Assessment, add the supplier's signature, and review the form for accuracy.
9. Once you are satisfied with the information entered, you can save changes, download, print, or share the completed form as required.

Start completing your Home Evaluation Form online today for a smooth submission process.