Medicaid Forms

The links below are provided to enable our clients' therapists and Custom Mobility to more rapidly process the service requests of our customers. If you have questions regarding completing these forms please contact our office.

Wheelchair Eval Form (Medicaid 2007) <Right-click on the link and choose "Save Target As...">

Custom Wheelchair Evaluation Form (Editable) <Right-click on the link and choose "Save Target As...">

We have also compiled an outline to follow when writing a letter of medical necessity instead of using the Medicaid Evaluation form. Please see the link

Outline for the Medicaid Justification Letter <Right-click on the link and choose "Save Target As...">