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 form must be completed by the licensed therapist or the certified physiatrist performing the evaluation. The evaluator may choose to include additional information that substantiates medical necessity for the equipment requested.

This Form Is Accepted By All Health Plans Including Medicare.

If a physician’s signature is required OR you are unable to view the custom wheelchair evaluation form in your browser or mobile device, you may click here to view and download the form. [Please print and fax the completed form to: (855) 834-7315]