MEDICAL JUSTIFICATION
Statement of Medical Necessity and Equipment Justification
Powered Mobility and Adaptive Seating Assessment
DATE/S OF ASSESSMENT:
PATIENT'S NAME:
D.O.B.: AGE:
PARENTS:
ADDRESS:
PHONE:
MEDICAL DIAGNOSIS:
THERAPISTS EVALUATING:
OTHERS PRESENT:
Medical Necessity and Justification for Equipment
Identification of Needs/Reason for Referral
Medical Considerations and/or History
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Motor Assessment
Reflexes and Abnormal Muscle Tone:
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Range of Motion/ Motor Strength:
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Voluntary, Isolated, Controlled Movements:
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Accuracy, Fatigue, Endurance:
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Sensory-Motor Patterns and Processing:
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Current seating
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Current Seating Recommendations
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Current Body Measurements
Description / MeasurementSeat to shoulder
Seat to head
Seat to axilla
Shoulder width
Chest width
Hip width
Back of chair to back of knee
Bottom of knee (seat) to bottom of heel
Equipment Trial
Equipment Used:
Invacare’s Power Tiger with power tilt
Means of Activation:
Adaptive Switch Labs’ Stealth proximity switch head array
Results of Trial:
Powered Chair Recommendations
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Training and Practice
On the day of delivery, after the seating has been completed, and the fitting is in place, an initial lesson will occur. At this time, the family will be taught how to manage the chair and a training schedule and plan for student name chair use will be made. It is critical that training occur at an individual and appropriate pace. Often, this lack of training is why a powered chair is never fully mastered. The chair changes the entire environment of student name and her family. ALL of them need to feel safe, secure, and competent in its use.Usually it takes about 6-12 months for an individual like student name to become completely competent withtheir chair (this means using the chair in familiar and unfamiliar environments.) I usually see them initially,
then once in about 2-4 weeks for a follow-up for both a check on the system, their use of it, and the seating.Any physical changes or adjustments can be made at that time. Then I see the patient at least once in their own living environment where the chair is primarily used. A treatment/training schedule is developed for thepatient and the family. It is done over time and depends on how quickly and safely the patient learns.
Primary Use of powered chair
Student name will be using the chair for independent mobility. She will also be able to re-position herself in the chair with the addition of a powered tilt system. This would allow her to change her position herself. It would also allow her attendants to change her position electronically, saving their backs and maintaining their health, too.
SPECIFIC EQUIPMENT RECOMMENDATIONS
***Please note: These specific items are the exact items that this person needs. The specifications and brands themselves should not be changed. They have been chosen with great care, for durability, ease of use, compatibility, and accessibility and for this individual's own particular needs. (These prices are not exact but, approximate and current as of the time of the report, actual prices will come from the manufacturers, themselves, at the time of purchase.)
1. Type of chair approximate cost
Description / Estimated costInvacare 2nd generation Storm Arrow w/o electronics
w/weight shift basic tilt wit back posts
w/Visual Display with switches & controller ONLY
w/ 14” seat width / n/c
w/17” seat depth / n/c
w/20” back height / n/c
w/flip back full length armrests / n/c
w/Storm hanger weldment / n/c
w/ 70 degree swingaway footrests
w/adjustable angle, flip-up footrests
w/ Short Base / n/c
w/8” x 1 3/4” semi-pneumatic casters / n/c
w/14” x 3” tires with flat free inserts
w/easy remote programmer
w/ group 24 gel batteries
w/variable speed actuator controller
w/communication (ECU) module
w/recliner cable
w/24 volt power source adaptor cable
From: Invacare, 899 Cleveland St., Elyria, OH 44036-4028; 1-800-333-6900
Local: America’s Best Dealer, 333 Unknown Blvd., Somewhere, PA Attn: Harry Harrison
2. Customized Adaptive Seating Insert
Description / Estimated CostSolid padded seat w/1 1/2” soft Sunmate foam, 14” wide x 16” deep, full width seat, with Rubitex fabric cover
Powder coated, 5-hole setlock bracket for adjustable angle on seat
Square, 2 hole hook (for set-lock brackets for angled seat)
4” x 12” lateral thigh/hip guide pads, black Rubitex
Solid, padded back w/ 1” soft Sunmate foam, 14” wide x 18” high, drop in-style, black Rubitex fabric $
Full width Back modification
Knob-release hardware kit for back
POSAfit lateral pads, pediatric, curved
2 “ offset brackets for lateral pads
Clear tray, small
Channel mount tray hardware
Dual pull padded, pelvic positioning belt w/push button buckle
Trim-line front -pull shoulder harness
From: Adaptive Engineering Labs, PO Box 12930, Mill Creek, WA 98082-0930; 800-327-608
From: Bodypoint Designs, Inc., 704 NE Northlake Way, Seattle, WA 98105; 800-547-5716
Local: America’s Best Dealer, 333 Unknown Blvd., Somewhere, PA Attn: Harry Harrison
3. Switches & Interfaces
Description / Estimated CostTwo Buddy button switches, one blue one red
ASL105C-M4, Mini MKIV Ready Head Array
-with Forward Switch Disconnect
-with “omit #210 beam switch” & add #208 proximity switch
Visual Display Drive Select Modification
Remote Attendant Control, #520-BG
From: TASH, Inc., Unit 1, 91 Station Street, Ajax, Ontario, Canada L1S 3H2; 800-463-5685
From: Adaptive Switch Labs, Inc., 125 Spur 191, Suite C, Spicewood, TX 78669; 800-626-8698
Local: America’s Best Dealer, 333 Unknown Blvd., Somewhere, PA Attn: Harry Harrison
4. Delivery Assembling, Instruction, Training
Both the therapist and the dealer/vendor need to be involved and working together. This is another critical piece of this entire chair actually working. This whole chair needs to be
assembled and checked, so that each piece fits, and to change a piece if it does not. There is regularly a time delay in the process of ordering and delivery. This system must be SAFE and FIT Student name exactly. This is the final customization and one of the most important parts of the entire process.
5. Choosing a medical supplier/dealer.
If there are any questions or concerns regarding this report, please contact:
(Fill in therapist name and contact info)