Get Smd-001 Category 1 And 2 Manual Wheelchair Application - Smd Mb

The SMD-001 Category 1 And 2 Manual Wheelchair Application is a crucial document for individuals seeking wheelchair services. This guide will assist users in effectively completing the form online, ensuring that all necessary information is accurately provided.

Follow the steps to successfully complete your application.

1. Click the ‘Get Form’ button to access the application and open it for completion.
2. Begin by filling out the client information section. Please provide your first name, last name, date of birth, gender, home address, city, postal code, and contact numbers. Ensure all details are clearly printed.
3. Indicate your current situation by specifying whether you are submitting a new application or an exchange application. If applicable, provide reasons for the exchange.
4. In the client information section, answer questions regarding your hospital status, your ability to pick up the wheelchair, and provide details for a contact person if necessary.
5. Complete the billing information section by answering eligibility questions related to other funding sources. If applicable, fill in funding numbers for NIHB or Veterans Affairs.
6. Fill out the next of kin details, ensuring that the individual resides in Manitoba. Provide their relationship to you and their contact information.
7. If funded by NIHB, complete the physician section by including your physician's name, signature, registration number, and contact information.
8. Complete the prescriber section, noting that only registered nurses or physicians may prescribe the requested category of wheelchair. Ensure all required details are included.
9. In the eligibility section, provide information on your primary diagnosis, functional mobility status, and method of propulsion. Choose options that accurately reflect your mobility needs.
10. Specify the current weight and height, and provide measurements as requested for wheelchair specifications, including seat dimensions and wheelchair category.
11. Fill out the wheelchair specifications section, including any justification for required features, and confirm whether the prescribed wheelchair will fit in your home environment.
12. Complete the equipment loan agreement and privacy statement. Read the terms carefully before providing your signature, and ensure a witness signs if required.
13. After filling out the entire form, review all information for clarity and completeness. Save your changes, then download, print, or share the completed application as necessary.

Complete your SMD-001 application online today to ensure you receive the necessary wheelchair services.