Wheelchair Intake Form

AHHE WHEELCHAIR INTAKE FORM

Patient Name: ______Date: ______CSR: ______

Referral Name: ______Title:______Contact ph #:______

1. What is the limitation of mobility (impairment of ambulation) that requires an assistive device?

Diagnoses ______

Physical condition (limitation) ______

2. Can the patient use a CANE for ambulation to complete MRADLS (Mobility Related Activity of Daily Living Skills) and is patient able to use the cane safely?

¨  YES If yes, is patient safe using a cane in home? YES NO, if no go to 3.

¨  NO

******************IF YES STOP (cane is reasonable & necessary) ***************

3. OR- Does patient require a WALKER for increased stability not provided by a cane and can they complete their MRADLS with the use of a walker?

¨  YES If yes, is patient safe using a walker in home? YES NO, if no go to 4.

¨  NO

*****************IF YES STOP (walker is reasonable & necessary) ***************

4. Can the patient self propel in any type of manual wheelchair?

¨  YES, Is patient safe with use of manual wheelchair? YES NO

¨  NO, Is a caregiver available, willing and able to push the manual WC? YES NO

IF NO, refer to REHAB Dept. for possible Scooter or PWR WC

5. Does the patient need and use the wheelchair for MRADLS inside the home?

¨  YES

¨  NO, If no the patient will not qualify for insurance to pay for wheelchair.

************ IF YES STOP (STANDARD WC (K0001) is reasonable & necessary) *********

If other than a K0001 is being ordered, document qualifications below (see attached guidelines)

(Circle one) K0002 K0003 K0004 *K0005 K0006 K0007

Height: ______Weight: ______Accessories: cushion ____ arm trough ____

brake extensions ____ anti tippers ____ seat belt ____footrest ____ ELR’s ____ ALR’s ____

ramp ____

______

*K0005 refer to REHAB Dept.

WHEELCHAIR GUIDELINES

Standard Base (K0001) - Above algorithm plus qualifying DX and medical notes.

Hemi Height (K0002) - Shorter seat than standard base needed for patient to place feet on floor to assist with propulsion or for assisting with stand pivot transfers.

Light Weight (K0003) - Unable to self propel in a standard weight because of physical condition or surfaces in home (carpet ect). If due to home environment documentation of condition must be documented.

High Strength Light Weight (K0004) - Why does patient require this base over a lower level base related to their activity? Must be highly active and in chair greater than 2 hours a day ***OR*** need a seat width, depth or height that is NOT available in a lower level chair.

Ultra Light weight (K0005) - Individual consideration. What is patient in now? What are activities that patient completes daily (both inside and outside the home) that they cannot complete in a lower level base. What is available on a K0005 that is not available on a K0004. What does the patient do daily that requires this level of chair to remain independent? (i.e. Patient gets up does personal hygiene, prepares meals, gets ready for work, takes care of household, shops, cleans, interacts socially just as you or I except from a wheelchair)

Heavy Duty (K0006) - Weight greater than 250# or spasticity diagnosis.

Extra Heavy Duty (K0007) – Weight greater than 300#.

All Bases - In addition to the above specific criteria ALL BASES must be required for the patient to complete MRADLS inside the home along with a qualifying diagnosis.

The medical reasons to support the need of any wheelchair must be documented in the patient’s medical chart and forwarded to AHHE.

REQUIRED DOCUMENTATION

1. Dispensing orders should contain the patient name, item description, and physician name, start date of order (this can be written or verbal).

If verbal you need a copy of your Confirmation of Verbal Order. Confirmation of verbal order should include all information received from the person calling. Verbal orders can be received from the ordering practitioner’s chain of command: Social worker, discharge planner, home health nurse, office staff, PT, OT, etc.

AND/ OR

2. Detailed or Written Order:

Patient name

Detailed description of item (with accessories)

Treating practitioners’ signature (physician, LNP, PA or CNS)

Start Date of order, if different from practitioners signed date.

Confirmation of Verbal Order can serve as a valid detailed/written order if all items above are included.

3. Medical Records that document necessity for the specific WC being ordered.

S:\Desktop Procedure\Equipment-Supplies (Qualifications-Medical Necessity)\Wheelchairs & Cushions

REV 07/16/2010 aje