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Justification Of Medical Necessity For Seating Wheeled Mobility BWC-1317 - Ohio
|Justification Of Medical Necessity For Seating Wheeled Mobility Form. This is a Ohio form and can be used in Medical Providers Workers Comp .||
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Better Workers' Compensation Built with you in mind. JUSTIFICATION OF MEDICAL NECESSITY FOR SEATING/WHEELED MOBILITY INSTRUCTIONS: ·Please print or type all information. ·This form must be returned to local service office and accompany all wheeled mobility requests. ·Complete Section I and Section V for standard wheelchair justification. ·Complete Section I through Section V for specially sized or constructed wheelchair, wheelchair with custom molded seating or specially adaptive positioning devices, power wheelchair and three-wheeled vehicle justification. SECTION I - GENERAL INFORMATION Injured worker's name Diagnosis, include description and ICD-9 code Prognosis Claim number Type of present wheelchair Age of wheelchair Describe the problem with the present equipment: Describe the equipment that is being requested: Describe the three most important facts this reviewer should be aware of: 1. 2. 3. Are there any medical conditions which are unrelated to the allowed injury? . . . Yes No If yes, please describe: SECTION II - MEDICAL/PHYSICAL/FUNCTIONAL STATUS Cardio-respiratory status: Tone/movement: Orthopedic considerations: Cognitive level: Visual/perceptual deficits: CLINICAL OBSERVATIONS Weight Sitting posture Pelvic tilt Leg position Thoracic Kyphosis Head position Susceptible to decubitus ulcers Sensation Present/history of ulcers Location ischial tuberosity Location trochanter Wheelchair dependent Yes No Height Balance Pelvic obliquity Lumbar lordosis Scoliosis Shoulder/scapula position SKIN CONDITION/INTEGRITY If yes, explain Bowel/bladder status Location coccyx Location spinous process Time spent per day in W/C Yes No If yes, explain BWC-1317 (Rev. 11/4/1997) C-190 2002 © American LegalNet, Inc. SECTION II - MEDICAL/PHYSICAL/FUNCTIONAL STATUS - CONTINUED FUNCTIONAL STATUS Upper extremity function ROM limitations Muscle strength limitations ADL status Lower extremity function Transfers Ability to perform pressure relief Wheelchair accessibility of residence Method of wheelchair transportation Wheelchair propulsion SECTION III - EQUIPMENT JUSTIFICATION Is there other related equipment to be evaluated or considered Yes No If yes, explain Therapeutic objectives/benefits of prescribed equipment Other special considerations Length of time wheelchair will be needed SECTION IV - EQUIPMENT PRESCRIPTION Mobility base Seating/positioning components Notes SECTION V - EVALUATOR Evaluator's signature Name (please print) Address Credentials Physician Phone ( ) State License No. L.P.T. O.T. L/R FAX ( ) 9 digit ZIP Code 2002 © American LegalNet, Inc.