Mobility Evaluation Report for Power Wheelchair - Horizon NJ Health 2026

1. Click ‘Get Form’ to open the Mobility Evaluation Report in the editor.
2. Begin by filling in the 'Date of Request' and select whether this is an 'Initial' or 'Replacement' request. Provide the member's name, date of birth, and ID number.
3. In the 'Current Symptoms, Related Diagnosis, and History' section, check all applicable medical conditions that limit mobility. Ensure this section is completed by the treating practitioner.
4. Proceed to the 'Physical Exam' section where height, weight, and other relevant health indicators must be recorded. This information is crucial for assessing mobility needs.
5. In the 'Power Wheelchair – Mobility Evaluation Report' section, indicate which Activities of Daily Living (ADLs) cannot be performed without powered mobility equipment. Provide detailed explanations for why alternative mobility aids are insufficient.
6. Finally, ensure that all required signatures are obtained from the physician or treating practitioner before submitting the form.

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