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 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 custom wheelchair evaluation form in your browser or mobile device, you may click the following link to view and download the form:

https://custom-mobility.com/uploads/custom-wheelchair-evaluation-form.pdf

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