Mobility device authorization 2026

1. Click ‘Get Form’ to open the Mobility Device Authorization Form in the editor.
2. Begin by filling out the Provider Information section. Enter the provider's name, NPI/UMPI, contact name, and phone number.
3. Next, complete the Recipient Information section. Fill in the recipient's last name, first name, diagnosis code, height, weight, date of birth, and MHCP ID number.
4. Describe any cognitive and communication impairments of the recipient and their living arrangements. Indicate if they require assistance for activities of daily living (ADLs) and provide details.
5. In the Mobility Device Requested section, specify whether a power or manual device is needed. Provide details about the make and model along with a description of medical necessity.
6. Document trials of requested equipment in various environments to ensure it meets needs. Include information on accessibility features like ramps or elevators.
7. Finally, gather all necessary signatures from involved professionals and attach any required documentation before submitting your form.

Start using our platform today to streamline your mobility device authorization process for free!