Form HFS3701L "Standard Manual Wheelchair Questionnaire" - Illinois

What Is Form HFS3701L?

This is a legal form that was released by the Illinois Department of Healthcare and Family Services - a government authority operating within Illinois. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2013;
  • The latest edition provided by the Illinois Department of Healthcare and Family Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form HFS3701L by clicking the link below or browse more documents and templates provided by the Illinois Department of Healthcare and Family Services.

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Download Form HFS3701L "Standard Manual Wheelchair Questionnaire" - Illinois

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State of Illinois
Department of Healthcare and Family Services
Standard Manual Wheelchair Questionnaire
Participant's Name
RIN
Birth Date
Height
Weight
Participant's Hip Width
Procedure code and description of wheelchair
Weight capacity of wheelchair
Width of wheelchair
Diagnosis
Current ambulation status
Upper body control and strength
Does participant have the ability to self propel?
Yes
No
If not, why?
If the participant is unable to safely self-propel the manual wheelchair does he/she have
a caregiver who is available, willing, and able to provide assistance with the wheelchair?
Yes
No
Does the participant need wheelchair to meet activities of daily living over the use of a walker or cane? Yes
No
If not, why?
ls this being requested for temporary use for injury or post op?
Yes
No
If yes, date of injury or surgery
Expected duration of need
*All requests for renewal of post surgical/post injury wheelchairs will require updated MD script along with copy of MD clinical
follow-up progress note.
Will this manual wheelchair meet participant's long term needs (3-5 years) or will participant need a customized wheelchair?
Physician's Name
Telephone Number
Attending Physician's Signature
Date Signed
HFS 3701L (N-8-13)
State of Illinois
Department of Healthcare and Family Services
Standard Manual Wheelchair Questionnaire
Participant's Name
RIN
Birth Date
Height
Weight
Participant's Hip Width
Procedure code and description of wheelchair
Weight capacity of wheelchair
Width of wheelchair
Diagnosis
Current ambulation status
Upper body control and strength
Does participant have the ability to self propel?
Yes
No
If not, why?
If the participant is unable to safely self-propel the manual wheelchair does he/she have
a caregiver who is available, willing, and able to provide assistance with the wheelchair?
Yes
No
Does the participant need wheelchair to meet activities of daily living over the use of a walker or cane? Yes
No
If not, why?
ls this being requested for temporary use for injury or post op?
Yes
No
If yes, date of injury or surgery
Expected duration of need
*All requests for renewal of post surgical/post injury wheelchairs will require updated MD script along with copy of MD clinical
follow-up progress note.
Will this manual wheelchair meet participant's long term needs (3-5 years) or will participant need a customized wheelchair?
Physician's Name
Telephone Number
Attending Physician's Signature
Date Signed
HFS 3701L (N-8-13)