Get Tx F00097 2021-2025

The TX F00097 form is essential for obtaining wheelchair seating evaluations through the CSHCN Services Program. This guide provides clear, step-by-step instructions to help users complete the form accurately and efficiently.

Follow the steps to successfully complete the TX F00097 online

1. Click the ‘Get Form’ button to access the form and open it in your preferred online editor.
2. Review the general information section carefully to ensure you are using the most recent version of the TX F00097 and understand the submission requirements.
3. Begin filling out the Prior Authorization Request Submitter Certification Statement by reading the statement and selecting 'We Agree' to confirm your understanding.
4. In the Client Information section, enter the client’s first name, last name, CSHCN Services Program number, date of birth, height, weight, address, and diagnosis codes.
5. Move to Part I – Neurological Factors. Indicate the client’s muscle tone and describe active and passive movements influenced by this tone.
6. Continue to Part II – Postural Control. Provide details about the client's control over their head, trunk, and extremities, as well as any history of skin breakdown.
7. In Part III – Medical/Surgical History and Plans, record any orthopedic conditions, recent physical changes, and any anticipated surgeries.
8. Proceed to Part IV – Functional Assessment. Indicate the client’s ambulation status, transfer capabilities, and feeding assistance needed.
9. Complete Part V – Environmental Assessment by describing the client’s home and school accessibility.
10. In Part VI – Requested Equipment, detail the current seating system, requested wheelchair type, and reasons for the request. Also, indicate medical necessity and anticipated modifications.
11. If applicable, complete Part VII – Power Wheelchairs by justifying the need for a power vs. manual wheelchair and providing therapist details.
12. Finally, ensure all required fields marked with an asterisk are completed. Review the form for accuracy before saving, downloading, printing, or sharing.

Complete your TX F00097 form online to enhance your submission experience.