Get Nj Horizon Mobility Evaluation Report For Power Wheelchair 2018

Filling out the NJ Horizon Mobility Evaluation Report for Power Wheelchair is an essential step in ensuring that users receive the mobility equipment they need. This guide will walk you through each section of the form, providing clear and concise instructions for completing it online.

Follow the steps to complete the form accurately and efficiently.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the date of request at the top of the form. Ensure the format is clear and legible.
3. Indicate whether this is an initial request or a replacement by selecting the appropriate checkbox.
4. Fill in the member's name and identification number (Member ID #) as accurately as possible.
5. Provide details about the DME provider, including the provider’s name, contact person's name, contact phone number, and fax number.
6. Enter the date of birth (DOB) of the member to confirm their identity.
7. In the current symptoms, related diagnosis, and history section, list the medical conditions that limit the member's mobility by checking the relevant boxes.
8. Describe how these conditions interfere with the member's ability to perform activities of daily living by selecting the appropriate checkboxes.
9. Complete the physical exam section, providing measurements for height and weight, and answering yes or no to questions regarding shortness of breath and overall health.
10. Indicate the member’s ability to perform activities of daily living that require powered mobility support by checking the relevant boxes.
11. Provide responses to the questions regarding mobility equipment needs, including why a cane or walker are insufficient options.
12. Verify if the member has the ability to sit erect and can safely operate a scooter by checking the appropriate options.
13. Finally, ensure that the treating practitioner signs and dates the form to certify that the information is accurate.
14. Users can then save changes, download, print, or share the form as necessary.

Complete your NJ Horizon Mobility Evaluation Report online to facilitate the mobility needs for users.