Fillable MEMBER INFORMATION Print Form (CalOptima)

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MEMBER INFORMATION Print Form (CalOptima)

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Custom Wheelchair Evaluation Request
Information to accompany Clinical Questionnaire
MEMBER INFORMATION
Fax information to CalOptima at 714-481-6516
Patient Name: _________________________________________________________________________ Date of Birth: _____________ Age: _________
(First) (MI) (Last)
Medi-Cal Number (CIN): _____________________________________________ Gender: Female Male Phone:
Patient Address:
_____________________________________________________ City: _______________________________ ZIP: ___________________
Home
Board and Care
ICF-DD SNF
Other: _______________________________________________________________________
Facility Name:
Language: Patient Speaks:
Patient Understands:
Caregiver / Family member participating in assessment and fitting
YES
NO
N/A
If yes, language spoken: ______________________
Transportation:
Self / Family / Caregiver
Public
OR
Medically necessary:
Littervan
Basic Ambulance
PRESCRIPTION
(Rx must be completed, signed, and dated by attending physician.)
Prescribing Physician ________________________________________
Primary Care Physician (PCP):
Medi-Cal Provider ID #
Medi-Cal Provider ID #
Phone: ______________________ Fax:
Phone:
Fax:
Address ___________________________________________________
Address
Primary Dx: __________________________________________ ICD-10:
Current Functional Status:
Current Wheelchair:
YES
NO If “YES”:
Manual
Power
Tilt/Recline Year:
Serial #:
Custom DME Prescribed:
Therapeutic Cushion
Manual Wheelchair
Power Wheelchair
Not Specified
M. D. Signature: __________________________________________________________________________________ Date:
Preferred Vendor:
(If provider or member does not designate, CalOptima will assign DME vendor.)
AUTHORIZATION
(For CalOptima Use Only)
Eligibility Date:
Health Network: _________________________________ Other Health Coverage:
Medicare
N/A
Utilization Contact:
Phone:
FAX:
_________________
Approved Codes:
S100C & S200C (Therapeutic Seat Cushion and/or Positioning System & Post Delivery Assessment/Fitting)
S101C & S201C (Custom Foam/Molded Cushion & Post Delivery Assessment Fitting)
S 102C & S202C (Manual Wheelchair With or Without Therapeutic Cushion & Post Delivery
S103C & S203C (Manual Wheelchair W
ith Pos
itioning System, With or Without Therapeutic Cushion & Post Delivery Assessment/Fitting
S 104C & S204C (Power Wheelchair With or Without Therapeutic Cushion & Post Delivery
AS105C & S205C t/Fitti ) (Power Wheelchair With Power Tilt/Recline or Specialized Driving Controls & Post Delivery
S300C & S301C (In-home assessment by DME Assessment Provider & Post Delivery Assessment/Fitting)
Approved Provider: _______________________________________________________________________________________________________
Authorization #: __________________________________ Date Approved: ________________ Date Sent: _______________ By:
Fax
Mail
Records Attached:
Progress Notes
H&P
Therapy Notes
Operative Report
Acute/LTC Facility Notes
Previous Equipment Repairs
Denied M.D. Signature: ________________________________________________________ Date:
Print Form
Revised:08/16/16
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MEMBER INFORMATION Print Form (CalOptima)

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Completed 11 March 2021

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