Wheelchair Seating Mobility ClinicsOhio State Medical Center 2026

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Click ‘Get Form’ to open the Wheelchair Seating Mobility ClinicsOhio State Medical Center form in the editor.
Begin by filling out the 'Date form completed' field at the top of the form. This helps track when the referral was made.
In the 'REFERRAL FOR' section, select all applicable services such as 'Wheelchair Seating/Mobility Assessment' or 'Motor Access to Technology'.
If applicable, provide the name of the wheelchair supply company in the designated field.
Complete personal information under 'CLIENT INFORMATION', including client name, date of birth, and primary diagnosis.
Fill in insurance details under 'MEDICAL INSURANCE / OTHER PAYER INFORMATION', ensuring accuracy for billing purposes.
Review and sign the CLIENT ACKNOWLEDGMENT AND AUTHORIZATION section to confirm understanding of services and billing.
Finally, ensure all sections are complete before submitting via fax or email as indicated at the bottom of the form.

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