Level of need form printable 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient's information in the designated fields, including First Name, Last Name, Date of Birth, and Medicaid number. Ensure accuracy as this data is crucial for processing.
3. In the Diagnosis section, provide a detailed explanation of the patient's transportation limitations. This is mandatory for determining appropriate transport options.
4. Fill out the Living Arrangements section by indicating whether the patient lives alone or with others. Specify any recent hospitalizations or surgeries that may impact their mobility.
5. Assess and document the patient's physical abilities. Indicate if they can ambulate independently and list any assistive devices they use, such as walkers or wheelchairs.
6. Complete the Medical Professional Info section with your printed name, phone number, signature, and NPI number to validate the form.

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