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Getting Started
Get Diagnosed
Gathering Important Information
Organizing Your Information
The Educated Parent
Early Intervention
What To Do First
What is Early Intervention?
Keeping an IEP Notebook
Preparing for an IEP Meeting
Conducting an IEP Meeting
Individuals With Disabilities Act
IDEA ACT - A Quick Reference
IDEA Legal Text
Family Finances
Recommended Resources
Introduction to Universal Housing Design
Housing options
Building a New House ~ That Works!
Introduction to Universal Housing Design
Entrances and Thresholds
Single Family Home Resources
Remodeled Bathroom
Ceiling Lifts
Problem Spaces
Adding a Ramp
Good Restroom
Not So Good Restrooms
Great Space Adaptions
Not So Great Adaptations
Ramp Design
Ramp Design (Part 2)
Commercial Ramps
Public Access Ramps
Adding a Ramp
Retrofit Door Sill Ramp
Medical Bills
Filing an Appeal
Medical Expenses and Income Taxes
Finding Help for the Uninsured or Underinsured
Free or Discounted Prescription Programs
Medicaid Waivers
Legal Adults - Introduction
Guardianship and Declaration of Incapacitation
Establishing Guardianship and Obtaining a Declaration of Incapacitation
Dependency Determination (Military)
When to Start the Transition Process
Begin Transition - Age 14-16
Exploring Possibilities and Guardianship Issues - Age 17
Age 18
After High School Graduation - Age 19-22
Post High School Education Options
Future Housing Options
Specialized Medical Equipment
Wheelchair Evaluation
Wheelchair Safety
Introduction: Special Needs and the Military Family
DEERS & ID Cards
Dependency Determination
TriCare Introduction
TriCare Program Options
Exceptional Family Member Program (EFMP)
Individual Case Management
TriCare Extended Care Health Option (ECHO)
Early Intervention
Housing Options
Family Support Services
Community Contacts
Letters of Medical Sufficiency
Wheelchair Accessible Vans
Van Conversion: A good Example
Fund Raising - The Flamingo Air Project
Utah DSPD Complaint List Winter 2011

A Note to Providers

The wheelchair evaluation format below is meant to be used as part of an evaluation/pre-authorization package which will be submitted to an insurance provider. Please be sure to include supporting documentation from other medical professionals and others (Treatment notes from the Primary Care Provider (PCM/MD), school therapists and staff, vocational rehab specialists, transportation staff, etc.) as needed to support your request. Be sure to emphasize the client's health and safety when appropriate. It is important to match each feature of the wheelchair with a physiological need of the client making sure to communicate any negative repercussion to the client if the item is not used. Emphasize "prevention of...." where appropriate. Statements such as the Example below are highly recommended.


"Client has experienced an increase in hip flexor contractions primarily secondary to sitting all day in a static flexed seated position in wheelchair with no independent means of postural change - such as standing - that would bring hips out of flexion into extension and prevent further contraction of the hip flexors. The prescribed equipment will enable the Client to independently change position frequently throughout the day allowing hip flexors to stretch, decreasing the danger of permanent, or increased, contracture."

Be aware you will be dealing with companies, agencies and individuals, who do not know the client, know the provider and often not the vendor you are working with. The more complete your information package is, the better your chances of an approval the first time around.

Wheelchair Evaluation Format

  1. Client's Information



    Date of Birth:



    Phone Number:

    Insurance Provider:

    Insurance number:

  2. Evaluator Information





  3. Muscle Tone:

    Indicate client's muscle tone:

    Describe client's muscle tone:

    Describe active movements affected by muscle tone:

    Describe reflexes present:

  4. Postural Control:

    Head Control:

    Trunk Control:

    Upper Extremities:

    Lower Extremities:

  5. Medical/Surgery History and Future Plans:

    Is there any History of decubitus/skin breakdown?

    If the answer is yes, please explain:

    Describe orthopedic conditions and/or range of motion limitations requiring special considerations (i.e.: contractures, degree of spinal curvature):

    Describe other physical limitations or concerns (i.e. respiratory):

    Describe any recent or expected changes in medical physical functional status:

    If surgery is anticipated, please indicate the procedure and expected date:

  6. Functional Assessment:

    Ambulatory Status:

    Indicate the client's ambulation potential:

    Wheelchair ambulation:

    Is client totally dependent upon wheelchair?

    If no, please explain:

    Indicate the client's transfer capability:

    Is the client tube fed?


    Describe other activities performed while in the wheelchair:

    Other Equipment Used:

  7. Environmental Assessment:

    Describe where client resides:

    Are ramps available in the home setting?

    Is the home accessible to a wheelchair?

    Describe the client's educational/vocational setting:

    Is the school/workplace accessible to a wheelchair?

    Are there ramps available at the school/workplace?

    If the client is in school, has a school therapist been involved in the assessment?

    Name of school therapist:

    Name of school:

    Describe how the wheelchair is transported (By whom and how):

    Describe other types of equipment that will interface with the wheelchair:

    Describe where the wheelchair will be stored:

  8. Requested Equipment:

    Describe client's current seating system including mobility base and attachments, if any:

    Describe why current seating system is not meeting client's needs:

    Describe equipment requested:

    Describe the medical necessity for the mobility base and seating system and attachments requested (describe ALL features requested):

    • Wheelchair:
    • Seat system:
    • Seat Cushion:
    • Steering mechanism and needed features:
    • Footplate (Style and features):
    • Headrest:
    • Chest Restraint:
    • Chest Support:
    • Push handles:
    • Pelvic positioning belt:
    • Safety Features (Seat belt, travel harness, etc.):

    Describe the growth potential of equipment requested in number of years:

    Describe any anticipated modifications/changes to the equipment within the next three years:

  9. Power Wheelchair

    Is client unable to operate a manual chair even when adapted?

    Is self-propulsion possible but activity is extremely labored? If yes, please explain:

    Is self-propulsion possible but contrary to treatment regimen? If yes, please explain:

    How will the power chair be operated?

    Is the client physically and mentally capable of operating power wheelchair safely and with respect to others?

    Is the caregiver capable of caring for power wheelchairs and understanding how it operates?

    How will training for the power equipment be accomplished?