Ohio department of job and family services seating and mobility letter form 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Part A, filling in general information such as Name, Birth Date, Residence/Facility, Medicaid Billing #, Other Insurance, Weight, and Height.
3. Proceed to Part B1 for Clinical Assessment. Document the number of hours per day in the wheelchair, estimated length of need, date of onset/injury, diagnosis(es), presenting problem, prognosis, and three important facts for the reviewer.
4. Complete Part B2 by detailing sitting posture/balance and any functional status limitations. Ensure to explain why a custom seating system is necessary if applicable.
5. In Part C, list all necessary equipment components under the appropriate headings. This section must be completed by a licensed therapist.
6. Fill out Part D with vendor information including Make/Model Number for all wheelchair requests.
7. If applicable, complete Part E for Home Assessment regarding power wheelchair needs and accessibility considerations.

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