Physician’s Order- Walker/Crutches/Cane
Patient Information
Name:
Address:
HIC#: DOB: Height: ___ ‘ _____ ‘’ Weight: ___ LBS
Provider Information
Name: MEDSTUFF, Inc. Address: 10382 Ralston Rd
Arvada, CO 80004
Phone: 303-403-4142
Fax: 303-456-5170(Denver)
Fax: 303-403-4099(Arvada)
NPI Number:1649464249
Physician’s Order- Walker/Crutches/Cane
Diagnosis Code Description Length of Need: [ ]______Months [ X ] Lifetime
X
______
Please answer the following questions:
Yes No 1. Does the patient have a mobility limitation that significantly impairs his/her ability to participate in one or moreMRADL(Mobility Related Activities of Daily Living) in the home such as : toileting, feeding dressing, grooming, bathing in customary location in the home?
A mobility limitation is one that:
Yes No - Prevents the patient from accomplishing the MRADL entirely, or
Yes No - Places the patient at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform and MRADL; or
Yes No - Prevents the patient from completing the MRADL, within a reasonable time frame.
Yes No 2. Is the patient able to safely use the walker?
Yes No 3. Can the functional mobility deficit be sufficiently resolved with the use of a walker?
MAE (Mobility Assistive Equipment)
What is the limitation of mobility (impairment of ambulation) that requires an assistive device?
Yes No 1. Are there other types of limitations present?
a). If yes, circle all that apply:
Cognitive Visual Positioning Spasticity Environmental
Yes No 2. Can the limitation be compensated with other types of devices/situations?
a). If yes, circle all that apply:
Glasses Caregivers Assistance
Yes No 3. Can the patient safely use/operate the mobility device prescribed?
Yes No 4. Can the patient use a cane for ambulation to complete MRADLS (Mobility Related Activity ofDaily Living Skills) due to condition causing impaired ambulation, and is he/she able to use the cane safely?
Yes No 5. Does he/she require a walker for increased stability and security not provided by a cane?
Yes No 6. Can the item ordered be used in his/her usual environment for all MRADLS?
Yes No 7. Can the patient self propel in any type of walker?
Yes No a). Is he/she safe with the use of a walker?
Yes No b). Does the walker fit the patient and his/her usual environment?
Based upon the above information, the following items are needed by this patient for the stated length of need:
Date Needed Quantity HCPC Description
X 1E0114Crutches, underarm, other than wood, adjustable or
fixed,pair with pads, tips and handgrips
I, undersigned, certify that the above prescribed equipment and/or supplies are reasonable and medically necessary as part oftreatment for this patient. The need and medical necessity for the above listed equipment and/or supplies is documented in the patient’s medical record and is available upon request.
Physician’s Order- Walker/Crutches/Cane
______
(Physician’s Signature)
Physician’s Name:
Address:
______
(Date)
NPI Number:
Phone Number:
Fax Number: