FORMS

All the forms you need are here:

The SCOOTER Store - Our Process (PDF - 1.22MB)

Our proven process supports you and your patients, ensuring your patient receives the power mobility device they need to best meet their needs.

Power Mobility Device Face-to-Face Examination Checklist (PDF - 91KB)

The Centers for Medicare & Medicaid Services (CMS) is issuing this article as solely an educational guide to improve compliance with documentation requirements for the face-to-face examination that occurs prior to the physician or treating practitioner ordering a PMD for their Medicare patients. The article presents a checklist, which is a tool that providers may wish to use for this examination, in addition to some helpful tips to help providers and suppliers avoid denial of their PMD claims.

Source - DEPARTMENT OF HEALTH AND HUMAN SERVICES, Centers for Medicare & Medicaid Services

Power Mobility Device - 7 Element Order Prescription (PDF - 36KB)

Prescription form created to help you provide power mobility for your patient.

Texas Academy of Family Physicians (TAFP) Power Mobility Device Evaluation Form (PDF - 124.5KB)

From the TAFP:
Because family physicians prescribe most power mobility devices ... your Academy has developed a clinical guide for evaluating a patient for a power mobility device. The purpose of the guide is to assist the treating physician and assure conformance with Medicare’s extensive documentation requirements and face-to-face examination.

Source - TAFP, http://www.tafp.org/resources/usefulForms/

Power Mobility Device Coding Guide, (PDF format, 6MB)

Meeting Medicare's criteria for a power mobility device requires a patient have one or more impairments with mobility-related activities of daily living in the home, such as feeding, dining, grooming, bathing and toileting.

This chart details the most commonly used ICD-9 Provider and Diagnostic codes for Group 2 Chairs. These lists are not all-inclusive, nor are they intended to be directive or prescriptive towards your determination of individual coverage.

Clinical Criteria for Mobility Assistive Equipment (MAE) Coverage (PDF 105K)

The beneficiary, the beneficiary’s family or other caregiver, or a clinician will usually initiate the discussion and consideration of MAE use. Sequential consideration of the questions below provides clinical guidance for the coverage of equipment of appropriate type and complexity to restore the beneficiary’s ability to participate in mobility-related activities of daily living such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home.

Source - DEPARTMENT OF HEALTH AND HUMAN SERVICES, Centers for Medicare & Medicaid Services

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