This Education in Motion resource is also available as a printable PDF.
Do you need a combination assessment and justification for your wheelchair and seating evaluation? This form provides a fillable PDF for use in the clinic.
The first edition of this form was designed by Jill Sparacio and Jessica Presperin Pedersen in the early 2000s for the state of Illinois Medicaid program. The goal of the initial form was to decrease the need for writing a letter of medical necessity in paragraph form, which was time consuming and sometimes left out the assessment section. Sparacio and Presperin Pedersen asked Mike Babinec if they could expand on an evaluation form he developed. Babinec's form had the section with the graphics of the pelvis, spine, and body parts.
Sparacio and Presperin Pedersen expanded his evaluation to follow the process of what a therapist must consider when recommending equipment. They reviewed all the paragraphs pertaining to justification of each product quote and created a checklist of justification statements in a product flow from mobility base with all the components on a wheelchair followed by seating products. This form allowed therapists and third-party payers the opportunity to follow a step-by-step process for evaluation which paints a clear picture of the physical, functional, environmental, and participatory information pertaining to the patient/rider. The recommendation and justification of the equipment immediately follows.
After a trial period at Misericordia and the Rehabilitation Institute of Chicago, it was mandated by the state of Illinois for anyone seeking Medicaid reimbursement for wheelchairs. Several versions have been implemented since then and similar forms can be found on NRRTS, AOTA, and various supplier websites. It has been translated into several languages. Feel free to download it and add logos depicting the facility you work for. It has never been copyrighted so that Sparacio and Presperin Pedersen could share it for anyone's use. Please continue to credit the authors listed at the bottom.
DISCLAIMER: FOR PROFESSIONAL USE ONLY. THIS WEBSITE (AND THE DOCUMENTS REFERENCED HEREIN) DO NOT PROVIDE MEDICAL ADVICE. Sunrise Medical (CA) LLC ("Sunrise") does not provide clinician services. The information contained on this website (and the documents referenced herein), including, but not limited to, the text, graphics, images, and descriptions, are for informational purposes only and should be utilized as a general resource for clinicians and suppliers to then use clinical reasoning skills to determine optimal seating and mobility solutions for individual patients. No material on this website (or any document referenced herein) is intended to be used as (or a substitute for) professional medical advice, diagnosis or treatment. Never disregard your professional medical training when providing medical advice or treatment because of something you have read on this website (or any document referenced herein). Clinicians should review this (and any other materials) carefully and confirm information contained herein with other sources. Reliance on this website (and the information contained herein) is solely at your own risk.
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