Powered Mobility Order Form

I certify that the above prescribed equipment and/or supplies are reasonable and medically necessary as part of treatment for this patient.

The need and medical necessity for the above listed equipment and/or supplies is documented in the patient’s medical record and it is available upon request.

All information provided in this form is also addressed in the patient's medical records. I acknowledge the patient's medical equipment will be denied by their insurance if the chart notes do not properly match the information entered above.

(If any information is missing in the chart notes, please make accurate addendums before uploading them)