Get Mobility Evaluation Form

Completing the Mobility Evaluation Form online can be a straightforward process if you follow the right steps. This guide will walk you through each section of the form, providing clear and detailed instructions to ensure accuracy and completeness.

Follow the steps to fill out the form correctly.

1. Press the ‘Get Form’ button to acquire the form and open it in your preferred editor.
2. Begin by entering the recipient's name, height, Medicaid ID number, and weight in the designated fields. Ensure all information is accurate to avoid processing delays.
3. Indicate whether the recipient has an alternate insurance plan by selecting 'Yes' or 'No.' If applicable, provide the name of the insurance plan in the field provided.
4. Enter the provider information, including the provider's name, Medicaid provider number, address, city, state, zip code, telephone number, fax number, date of evaluation, and place of evaluation.
5. Detail the recipient's diagnosis clearly, using written descriptions instead of ICD-9 codes. Provide both primary and secondary diagnoses if applicable.
6. Assess the current ambulatory status of the recipient. Provide insights on their mobility, including questions about their ability to walk with assistance or use mobility aids.
7. Document relevant medical history by providing dates and descriptions of any recent surgeries or hospitalizations.
8. Describe the current seating system, including the make, model, and its condition, followed by detailing any problems with it.
9. Evaluate aspects such as the recipient's vision, cognition, ability to communicate, and daily activity level, offering comments and observations as needed.
10. Provide justification for medically necessary options and recommendations for the wheelchair or seating system. Ensure all proposed options are clearly justified.
11. Conclude by reviewing all entries for accuracy and completeness. Once finalized, you can save the changes, download, print, or share the completed form.

Complete your documents online today to ensure a smooth and efficient application process.