SECTION 6—Living Environment:
Number of hours per day in the wheelchair:
SECTION 8—Ambulation:
SECTION 7—Activity Level:
At home Outside For physician visits Job related activities School
House/condominium Apartment Stairs Elevator Ramp Hills SNF ICF/DD B&C
Living Assistance: Lives Alone With Other Person(s) Alone Most of the Day Alone at Night
Attendant Care: Live in attendant or Hours/day Homemaker Hours
Transportation:
SECTION 9—Wheelchair Base and Accessories:
1. Does the beneficiary require and use the wheelchair to move around in their place of residence?
SECTION 11—DME provider/Therapist attestation and signature/date:
By my signature below, I certify to the best of my knowledge that the information contained in this Certificate of Medical Necessity is true,
accurate and complete and I understand that any falsification, omission or concealment may subject me to criminal liability under the laws
of the State of California.
Name of therapist answering these sections, if other than prescribing clinician or DME provider (please print):
DME Provider Name:
(Use Ink - A signature stamp is not acceptable)
Name:
✍
(Please print) (Please print)
(Use Ink - A signature stamp is not acceptable)
✍
(OT, PT, RESNA, etc.)
Title:
Date:
SECTION 12—Clinician attestation and signature/date:
I certify that I am the clinician identified in this document. I have reviewed this Certificate of Medical Necessity and I certify to the best
of my knowledge that the medical information is true, accurate, current and complete, and I understand that any falsification, omission,
or concealment may subject me to criminal liability under the laws of the State of California.
(Use Ink - A signature stamp is not acceptable)
✍
Date:
Clinician’s Signature:
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❒
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Doorway widths and home layout for adequate wheelchair use indoors verified except: Bathroom ❒ Bedroom ❒ Kitchen ❒ Other:
To/from medical appointments?
❒
Yes Local Community?
❒
Yes
❒
No Beneficiary drives from the wheelchair?
❒
Yes
❒
No
Tie-down system:
Public Transportation:
Distances the beneficiary pushes/drives daily:
Beneficiary will use the wheelchair:
Social Activities
❒
SNF
❒
ICD/DD
❒
Who will propel this chair?
❒
Other: Beneficiary
Beneficiary can independently propel a manual wheelchair:
Beneficiary can disassemble this type of manual wheelchair and independently transfer self and chair to a motor vehicle:
Beneficiary is unable to effectively propel any manual wheelchair:
❒
Yes
❒
No
❒
Yes
❒
No
❒
Yes
❒
No
Beneficiary is independently ambulatory: Beneficiary is unable to walk:
❒
Yes
❒
No
❒
Yes
❒
No
Beneficiary ambulation is non-functional and limited by:
Beneficiary’s ambulation ability is expected to change:
❒
Yes
❒
No
Explain “Yes” Answer:
Beneficiary is scheduled for additional lower extremity medical/surgical intervention(s).
❒
Yes
❒
No
Explain “Yes” Answer:
❒
Yes
❒
No
2. Does the beneficiary have quadriplegia, a fixed hip angle, a trunk cast or brace, excessive extensor tone of the
trunk muscles or need to rest in a recumbent position?
❒
Yes
❒
No
3. The beneficiary has a cast, brace or musculoskeletal condition, which prevents 90 degrees of flexion of the knee,
or does the patient have significant edema of the lower extremities?
❒
Yes
❒
No
4. How many hours a day is this beneficiary expected to spend in this wheelchair? (Round to nearest hour)
5. Is this beneficiary able to adequately self-propel (without being pushed) in a standard weight manual wheelchair?
❒
Yes
❒
No
6. If the answer to question #5 were “No”, would this beneficiary be able to adequately self-propel (without being pushed)
in any type lightweight wheelchair?
❒
Yes
❒
No
SECTION 10—Narrative description of the wheelchair and cost and justification for higher cost frames, second wheelchair tilt recline:
Manufacturer:
Provider Location:
Model: Provider Name:
❒
At Home
❒
In the community
DHCS 6181-A (09/17)
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