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OMAP 3125 Wheelchair and Seating Justification and Prescription - dhsforms hr state or

OMAP 3125 Wheelchair and Seating Justification and Prescription - dhsforms hr state or-2026

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The document is a Functional Mobility Evaluation form used by the Division of Medical Assistance Programs to assess individual clients' needs for mobility equipment, such as wheelchairs. It includes sections for medical justification, needs assessment, and prescription details, allowing therapists and physicians to specify the client's diagnosis, current equipment issues, and required modifications or new equipment. The form emphasizes personalized evaluations to ensure that the prescribed mobility solutions support the client's functional capabilities and living situation.

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Click ‘Get Form’ to open the OMAP 3125 Wheelchair and Seating Justification and Prescription in the editor.
Begin by entering the client's personal information, including Name, Date of Birth, Recipient ID, Sex, Height, and Weight in the designated fields.
In the Medical Justification section, provide the Diagnosis along with the ICD-9-CM code. Detail any significant medical complications and physical capabilities.
Complete the Needs Assessment section by listing current wheelchair problems, equipment in use, living situation compatibility, and any alternatives considered.
In the Prescription section, indicate whether a new chair is needed or if modifications/repairs are required. Provide justifications for each choice made.
Fill out specifications for manual or powered mobility options as necessary. Ensure all relevant details about seating requirements are included.
Review all entries for accuracy before saving your completed form. Utilize our platform's features to sign and share your document easily.

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