Consent Form

Please download to review and sign this form, granting Custom Mobility Consent to work on your product. (If you are unable to view the form click here.) Please fax the completed form to: (855) 834-7315 If you are unable to view the consent form in your browser or mobile device, you may cl...

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Custom Wheelchair Evaluation Form

The intent of this form is to secure sufficient information to determine the medical necessity for a custom wheelchair request submitted for prior approval to Florida Medicaid. This form must be completed by the licensed therapist or the certified physiatrist performing the evaluation.  This...

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