Get Patient Report Copy

Filling out the Patient Report Copy is an essential step in applying for funding for a power mobility aid. This guide provides clear instructions on how to complete the form accurately and efficiently to ensure all necessary information is submitted.

Follow the steps to fill out the Patient Report Copy online.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Begin by entering the patient's name in the designated field. This section is crucial for identifying the person for whom the report is being completed.
3. Provide the primary diagnosis of the patient. This information helps establish the medical need for a power mobility aid.
4. Fill in the height and weight of the patient. Accurate physical measurements are important for determining the appropriate mobility aid.
5. List any other medical conditions that pertain to the need for power mobility. Detailed descriptions can help in assessing the applicant’s overall needs.
6. Select the patient’s primary method of mobility from the available options. This includes choices like unassisted or with aids such as a cane or wheelchair.
7. Describe the difficulties the patient faces with their primary method of mobility in the designated field. Providing clear examples will support the application.
8. Indicate whether the patient's physical condition necessitates a power mobility device by selecting 'No' or 'Yes'. Include justification if 'Yes' is selected, detailing the travel limitations.
9. If applicable, specify the most suitable type of power mobility aid, including options such as a three-wheeled scooter or power wheelchair, along with explanations for the choice.
10. Answer the question regarding whether the patient’s condition is progressive and requires continual reassessment. If so, provide details and recommendations for follow-up assessments.
11. Assess whether the patient has any visual, cognitive, or physical impairments that may affect safety while using the mobility aid. If 'Yes', note any necessary restrictions.
12. Ensure the physician responsible for this report acknowledges any associated costs by signing the form, including the date and printed name.
13. Provide the physician's phone number for further contact or clarification as needed.
14. Once all sections are completed, save your changes, then download, print, or share the completed form as required.

Complete your Patient Report Copy online today to streamline the application process for the power mobility aid.