Sample letter of medical necessity - Frank Mobility Systems
Sample letter of medical necessity - Frank Mobility Systems
Sample letter of medical necessity - Frank Mobility Systems
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FUNCTIONAL STATUSSitting Balance: Poor – dependent on external supportUpper Ext. Function: Poor – severe upper extremity weaknessTransfers: 2 person carry transfersW/C <strong>Mobility</strong>: Unable to functionally operate manual wheelchair – Patient will be bedconfined without power wheelchair.Daily W/C Use: 12 hours +Ambulation: Non-AmbulatoryADL: moderate – maximum personal assistanceTransport: VanLiving environment: accessible home private homeCurrent Equipment: owns no equipmentClinical and Home MOBILITY TRIAL:Patient had successful trial with recommended power assist manual wheelchair duringclinical trials at _____ ______ Hospital. DME supplier performed home accessibilitytrial with patient to all essential areas and deemed accessible.The following recommendation <strong>of</strong> durable <strong>medical</strong> equipment is found to be the mostcost effective system to meet this patient’s postural support and mobility needs and it ismade with recognition <strong>of</strong> this patient’s potential for growth and/or change.
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