File name: Illinois Wheelchair Assessment Form Pdf
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👉Illinois Wheelchair Assessment Form Pdf
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Blue Cross and Blue Shield of Illinois (BCBSIL) reviews requests for manual wheelchairs (MWCs) and power-operated vehicles (POVs) (i.e., Power Wheelchair, Scooter, Other POV) as . * Important Note: If you experience technical difficulties opening certain fillable PDF's, please right-click the form link, save the PDF to your device, then open the form outside of your browser. Wheelchair and Seating Evaluation: Jill Sparacio, Jessica Pedersen, Mike Babinec, Julie Piriano (, , , ) 5 / Patient Name: Comments A J B K C L D M E N F O G P H I o . HFS (N)State of Illinois Department of Healthcare and Family Services MOTORIZED WHEELCHAIR EVALUATION FORM Resident NameNursing Facility NameRecipient Identification Number (RIN) 1. Does person have a physical limitation that prevents him or her from accomplishing YesNo a mobility-related activity of daily living? 2. Blue Cross and Blue Shield of Illinois (BCBSIL) reviews repair, replacement and initial (first time) requests for manual wheelchairs (MWCs) and power-operated vehicles (POVs) (i.e., Power Wheelchair, Scooter, Other POV) as required according to details of our members’ benefit plans and medical necessity criteria outlined in BCBSIL’s Medical Pol. * Important Note: If you experience technical difficulties opening certain fillable PDF's, please right-click the form link, save the PDF to your device, then open the form outside of your browser.