Referral Resources


A face-to-face exam notating that the patient presents for a potential need for a power mobility device.

  1. The examination should include: height, weight, cardiopulmonary function, musculoskeletal (including strength/ROM) capabilities and neurological condition.
  2. The patient’s medical history, relevant to patient’s mobility needs in the home, should also be addressed. Focus on the body systems responsible for ambulatory issues in the home.

Chart notes/medical documentation should include the following:

  1. Symptoms that limit ambulation and the diagnoses responsible for these symptoms (including medications or other treatments that have been tried for these symptoms and/or diagnoses).
  2. Progression of ambulatory difficulty and the diagnoses related.
  3. Observation of walking distance, gait, and pace of ambulation. Was an assistive device (cane or walker) used? Or is the patient unable to bear any weight?
  4. History and frequency of falls; injuries related to falls, and which type of assistive device (if any) was the patient using when they fell?
  5. Which assistive device is the patient currently using? If the patient is unable to use a cane, walker or manual wheelchair, please specify the cause/reason.
  6. Why does the patient require a power mobility device at this time?
  7. State whether or not a patient can/cannot safely transfer. If ordering a scooter, can the patient operate the tiller? Is there sufficient space in the home to maneuver the power mobility device being ordered?
  8. How will the power mobility device help your patient complete his/her mobility related aids to daily living? Please be specific " i.e., to prepare/eat meals, use bathroom, etc.
  9. If the patient has the cognitive ability to safely operate, and is willing to operate the equipment in his/her home, please include this statement.

If for any reason you cannot thoroughly document all of the requirements mentioned, you may elect to refer the patient to a physical or occupational therapist to perform part of this evaluation. If you refer your patient, an Rx is required from you for this evaluation. Also, include a referral statement in the chart notes. Once the evaluation is completed, it will be forwarded to you for a concurrence statement. The date of the concurrence statement will become the new face-to-face date. If you have any questions regarding these requirements, please contact us at (248) 658-0988.

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