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(State of Indiana)

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U.S.A. forms for State of Indiana

BROWSE STATE OF INDIANA (IN) FORMS

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I n d i a n a H e a l t h C o v e r a g e P r o g r a m s
M E D I C A L C L E A R A N C E F O R M
P H Y S I C A L A S S E S S M E N T F O R S T A N D I N G E Q U I P M E N T
Section A: Patient information
Patient name Recipient identification number
Diagnosis
Onset date of disability Date of birth
Current weight Current height
Section B: Physician Information
Provider’s name Provider number
Section C: General Physical Status
*Please select the most appropriate answer. If abnormal or progress is selected, please explain in the space provided.
Cardiopulmonary status Normal Abnormal Progress
Explain:
Sensation/body awareness Normal Abnormal Progress
Explain:
Skin status Normal Abnormal Progress
Explain:
Sensation status Normal Abnormal Progress
Explain:
Muscle strength status Upper strength Normal Abnormal Progress
Lower strength Normal Abnormal Progress
Explain:
Muscle tone status Normal Abnormal Progress
Explain:
Range of motion (ROM) status Upper ROM Within functional limits (WFL) Abnormal Progress
Lower ROM WFL Abnormal Progress
Explain:
Standing static and dynamic balance Normal Abnormal Progress
Explain:
Sitting static and dynamic balance Normal Abnormal Progress
Explain:
Medical Clearance Form for Standing Equipment
Version 2.0, March 2015
Page 1 of 2
Section D: Requires Assistance With The Following
* Please select most appropriate answer
Ambulation
Independent
Maximum
Dependent
Transfers
Independent
Maximum
Dependent
Propelling wheelchair
Independent
Maximum
Dependent
Sitting
Independent
Maximum
Dependent
Feeding
Independent
Maximum
Dependent
Dressing
Independent
Maximum
Dependent
Hygiene
Independent
Maximum
Dependent
Section E: Rational For Use
*Please select yes or no
To maintain bone integrity and increase bone density
Yes
No
To improve circulation in the lower extremities
Yes
No
To improve range of motion
Yes
No
To decrease muscle spasms
Yes
No
To strengthen cardiovascular system and build endurance
Yes
No
To improve strength to the trunk and lower extremities
Yes
No
To prevent or decrease joint muscle contractures
Yes
No
To lessen or prevent progressive scoliosis
Yes
No
To aid normal skeletal development
Yes
No
Section F: Special Considerations
* Please select the correct answer or fill in the blanks
What is the height range and weight capacity of the stander requested?
Height range from to Weight capacity from to
Additional Comments:
What are the position needs? Supine Vertical Prone
Multipositional
Additional Comments:
What is the cost of the stander?
Please individually list each requested accessory and its cost:
How long will the stander be required? Months Years Lifetime
Additional Comments:
Is the nonpaid primary caregiver willing and able to be trained to use the equipment safely?
Yes
No
Additional Comments:
Assessment Completed By:
Date:
Section G: Physician’s Signature and Date
I certify the medical necessity of these items for this patient. I have examined the above-mentioned patient and
to my
knowledge there are no medical or surgical contraindications for the use of a stander.
Physician’s signature: Date:
Medical Clearance Form for Standing Equipment
Version 2.0, March 2015
Page 2 of 2
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document Name (State of Indiana)

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Completed 21 February 2022

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