QUALIFY - WHEELCHAIR

WILL YOUR PHYSICIAN (MD,DO, NP or PA) PROVIDE A DETAILED WRITTEN ORDER?

_____Do you have a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home.

_____If your mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker.

_____Does your home provides adequate access between rooms, maneuvering space, and surfaces for use of the manual wheelchair that is provided.

_____Will a wheelchair significantly improve the beneficiary’s ability to participate in MRADLs and the beneficiary will use it on a regular basis in the home.

_____Has the beneficiary not expressed an unwillingness to use the manual wheelchair that is provided in the home.

_____Does the beneficiary has sufficient upper extremity function and other physical and mental capabilities needed to safely self-propel the manual wheelchair that is provided in the home during a typical day. Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both upper extremities are relevant to the assessment of upper extremity function

_____Does the beneficiary has a caregiver who is available, willing, and able to provide assistance with the wheelchair.

If you answered yes to these question, have your physician fax info to Diamond 480.926.4364

Click DIAMOND DIRECT to go to wheelchair buy page