Express Medical Equipment, Inc. - Wheelchair Face To Face

Patient Name:

First Name

Last Name

DOB:

Dx.:

Height:

Weight:

A face to face with the above patient has been completed and I certify to it.

This patient needs a lightweight wheelchair due to:

Limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing customary locations in the home Patient’s mobility limitation cannot be sufficiency resolved by the use of an appropriately fitted cane or walker Use of lightweight wheelchair will significantly improve the patient’s ability to participate in MRADLs and the Patient will use it on a regular basis in the home The patient has sufficient upper extremity function and other physical and mental capabilities needed to safely self-propel the lightweight wheelchair that is provided in the home during typical day The patient has a caregiver who is available, willing, and able to provide assistance with the wheelchair The patient will spend at least 2 hours per day in the wheelchair The patient needs anti tippers for safe mobility and to prevent the wheelchair from tipping backwards The patient needs wheel lock extensions due to their limited upper extremely mobility

This patient needs a transport chair due to:

Patient is unable to propel themselves in a manual wheelchair due to lack of upper extremely strength and mobility The patient has a caregiver who is available, willing, and able to provide assistance with the transport chair

Physician Name:

Physician Signature:

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Date:

Physician NPI#: