Get the free Motorized Wheelchair Evaulation Form (pdf) - hfs illinois

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Signature of person completing form Date HFS 3867 N-3-07 E-mail hfs. webmaster illinois. gov IL478-2702 Internet http //www.

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What is motorized wheelchair evaulation form?

Motorized wheelchair evaluation form is a document that is used to assess the needs and eligibility of an individual for a motorized wheelchair. It helps in determining the appropriate type and features of the wheelchair that will best meet the individual's mobility requirements.

Who is required to file motorized wheelchair evaulation form?

Individuals who require a motorized wheelchair and are seeking assistance or funding from a healthcare provider, insurance company, or government agency are generally required to file the motorized wheelchair evaluation form.

How to fill out motorized wheelchair evaulation form?

To fill out the motorized wheelchair evaluation form, you need to provide personal information such as name, contact details, and date of birth. You will also need to provide details about your medical condition, mobility limitations, and any specific requirements for the wheelchair. Additionally, you may need to provide supporting documentation from your healthcare provider or therapist to support your need for a motorized wheelchair.

What is the purpose of motorized wheelchair evaulation form?

The purpose of the motorized wheelchair evaluation form is to ensure that individuals who require a motorized wheelchair receive the appropriate type and features of the wheelchair that will best meet their specific mobility needs. It helps healthcare providers, insurance companies, and government agencies assess the eligibility and funding assistance required for the provision of motorized wheelchairs.

What information must be reported on motorized wheelchair evaulation form?

The motorized wheelchair evaluation form typically requires information such as personal details (name, contact information, date of birth), medical diagnosis, mobility limitations, specific wheelchair requirements, and supporting documentation from healthcare providers or therapists. The specific information required may vary depending on the organization or agency receiving the form.

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