Get Tx F00097 2016

The TX F00097 form, known as the Wheelchair Seating Evaluation, is essential for individuals seeking proper seating solutions related to wheelchairs. This guide will provide you with step-by-step instructions on how to efficiently fill out the form online, ensuring that all necessary information is accurately included.

Follow the steps to complete the TX F00097 online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Read the prior authorization request submitter certification statement carefully and select 'We Agree' to confirm understanding and agreement.
3. In the Client Information section, accurately fill in the client's first name, last name, CSHCN Services Program number, date of birth, height, weight, address, city, state, ZIP, and relevant diagnosis codes.
4. Proceed to Part I for Neurological Factors, where you will indicate the client's muscle tone, describe active and passive movements affected, and note any reflexes present.
5. In Part II, assess Postural Control by indicating the head, trunk, upper extremity, and lower extremity controls, along with any history of decubitus or skin breakdown.
6. For Part III, detail the client's medical and surgical history and plans, including any orthopedic conditions or recent changes in medical status.
7. In Part IV, conduct a Functional Assessment by indicating the client's ambulatory status and transfer capabilities, as well as feeding and dressing capabilities.
8. Part V requires an Environmental Assessment. Describe the client's residential and educational environments regarding accessibility.
9. In Part VI, outline the requested equipment, detailing the client's current seating system, and the medical necessity for the requested wheelchair.
10. If applicable, in Part VII, provide details justifying the need for a power wheelchair, including how it will be operated and caregiver capabilities.
11. Complete the Measuring Worksheet if power wheelchairs are requested, detailing measurements related to the client's seated dimensions.
12. Before finalizing, review all filled sections for accuracy, then save, download, print, or share the completed form.

Complete your TX F00097 form online today for efficient processing.