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Medicaid wheelchair evaluation 2026

The document is a Wheelchair/Seating Evaluation form required by the Alabama Medicaid Agency, to be completed by licensed Physical or Occupational Therapists. It outlines the necessary information for evaluating a patient's need for wheelchair equipment, including medical history, current mobility status, and specific requirements for wheelchair features. The evaluation must occur in a hospital outpatient setting, and additional documentation may be requested to justify the need for the equipment.

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Click ‘Get Form’ to open the Medicaid Wheelchair Evaluation in the editor.
Begin by entering the patient's name and today's date at the top of the form. This ensures that all evaluations are accurately documented.
Fill out the referral information section, including details about any services being received, physician contact information, and the reason for referral.
Complete the patient information section, noting age, date of birth, and daily activities. Be sure to indicate handedness and any relevant medical history.
In the current wheelchair/seating system section, specify if applicable options like manual or power wheelchairs are being used. Include manufacturer details and dimensions.
Document transportation needs and communication abilities in their respective sections to provide a comprehensive overview of patient requirements.
Finally, review all entries for accuracy before saving or sharing your completed evaluation using our platform's features.

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