Get Power Mobility Devices And Custom Manual Wheelchairs ... - Hfs Illinois

This guide provides comprehensive and user-friendly instructions for filling out the Power Mobility Devices and Custom Manual Wheelchairs form required by HFS Illinois. By following these steps, users can ensure that their forms are completed accurately and efficiently.

Follow the steps to complete your application successfully.

1. Click ‘Get Form’ button to access the document and open it in your chosen editing tool.
2. Enter the patient's name in the designated field to clearly identify the individual requiring mobility assistance.
3. Fill in the RIN (recipient identification number) next to the patient's name for proper record-keeping.
4. Provide the patient's birth date to confirm their identity and age.
5. Print the physician's name and state license number to certify the evaluation.
6. Input the date of the face-to-face evaluation, ensuring accurate documentation of the evaluation timeline.
7. Include the physician's phone number for any necessary follow-up or clarification.
8. Specify the type of mobility device needed by checking the appropriate boxes for power wheelchair, power scooter, or custom manual wheelchair along with the duration of need in months.
9. Document the medical necessity for each item ordered on Form 3701H with a brief narrative description.
10. Indicate whether the evaluation has been delegated to another professional, and if so, provide their details separately.
11. Detail the patient's diagnosis, including the date of onset if known, and describe disabilities requiring mobility equipment.
12. Assess the patient's potential for improvement and outline any recent or upcoming surgeries that may affect mobility.
13. Record the patient's current weight along with their weight from the past one and two years.
14. For pediatric patients, describe their growth in height and weight over the past 2 to 5 years.
15. Confirm if the patient can operate the ordered equipment safely and whether they are restricted to operating it only in the home environment.
16. If a power wheelchair is ordered, explain why a power scooter cannot meet the patient's needs.
17. The physician must certify the truthfulness of the information provided and sign the form, including the date of signature.
18. After completing all sections, save any changes made, and consider downloading, printing, or sharing the completed form as needed.

Complete your documents online today and ensure the best possible support for mobility needs.