Get the free Powered bWheelchairb Referral Form - Leicestershire Partnership bb
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Specialist Mobility Center For Leicester, Leicestershire & Jutland We do not provide scooters or outdoor only powered chairs. Powered Wheelchair Referral Form This form should be completed and signed
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How to fill out powered bwheelchairb referral form
How to fill out a powered wheelchair referral form:
01
Start by filling out the patient's personal information, including their name, date of birth, address, and contact details. Ensure all information is accurate and up to date.
02
Next, provide details about the healthcare professional who is prescribing the powered wheelchair. This may include their name, specialty, contact information, and any relevant credentials.
03
Describe the patient's medical condition or disability that necessitates the use of a powered wheelchair. Be specific and provide any relevant medical history or diagnoses.
04
Include information about the patient's mobility limitations and how a powered wheelchair would improve their daily functioning and quality of life.
05
Indicate any previous attempts or alternatives that have been considered or tried for mobility assistance, as well as the reasons why a powered wheelchair is now deemed necessary.
06
If applicable, provide details about the patient's insurance coverage or funding sources for the powered wheelchair. This may include insurance policies, government programs, or other financial assistance options.
07
Finally, ensure all required signatures are obtained, including those from the prescribing healthcare professional and the patient or their guardian. Review the completed form for accuracy and completeness before submitting it.
Who needs a powered wheelchair referral form?
01
Patients who have limited mobility due to a medical condition, injury, or disability may require a powered wheelchair referral form.
02
Individuals who are unable to walk or have difficulty with mobility and require a motorized device for assistance may need a referral for a powered wheelchair.
03
The referral form serves as a means to assess the patient's eligibility and need for a powered wheelchair, ensuring that they receive appropriate and necessary mobility assistance.
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What is powered wheelchair referral form?
Powered wheelchair referral form is a document used to request authorization for a powered wheelchair for a patient.
Who is required to file powered wheelchair referral form?
Medical professionals such as doctors, therapists, or healthcare providers are required to file the powered wheelchair referral form.
How to fill out powered wheelchair referral form?
The form should be filled out with patient information, medical necessity details, and supporting documentation from the healthcare provider.
What is the purpose of powered wheelchair referral form?
The purpose of the powered wheelchair referral form is to ensure that patients receive the appropriate equipment needed for their mobility and health needs.
What information must be reported on powered wheelchair referral form?
The form must include patient's demographic information, reason for needing a powered wheelchair, healthcare provider's recommendation, and any additional documentation supporting the request.
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