Prescription Requirements
All Power Mobility Devices require a written prescription prior to delivery. The equipment supplier
is required by Medicare to have the written prescription, plus proof you have considered the 9 questions listed on the previous page, in their files prior to delivering the Power Mobility Device.The written prescription must contain the following:
| 1. |
Beneficiary's name |
| 2. |
Description of item that is ordered. This may be general - e.g. "power wheelchair" or may be more detailed. |
| 3. |
Date of the face-to-face examination |
| 4. |
Pertinent diagnosis/conditions that relate to the need for the Power Mobility Device |
| 5. |
Length of need |
| 6. |
Physician's signature |
| 7. |
Date of physician's signature |
Please forward the detailed written prescription, along with supporting documentation
to the 9 questions, to the equipment supplier as soon as possible to ensure
that your patient receives the prescribed equipment in a timely manner. The
supplier must receive the written prescription and supporting documentation for
the Power Mobility Device within 30 days from the date of the face-to-face examination (See following exception).
If all questions are not supported by the medical record history and cannot be addressed
through the face-to-face examination of the patient you may prescribe a physical/ occupational therapist wheelchair evaluation to address or support the remaining questions. (In the event you
refer your patient to a PT/OT for a wheelchair evaluation, you must obtain a copy of the written evaluation from the therapist and indicate concurrence or disagreement with the assessment. Please co-sign the assessment and submit a copy of the assessment with your written pre-
scription to the PMD supplier within 30 days of the date of your PMD prescription.)
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