"Questionnaire #4 - Seat Lift" - Colorado

Questionnaire #4 - Seat Lift is a legal document that was released by the Colorado Department of Public Health and Environment - a government authority operating within Colorado.

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  • Released on September 1, 2015;
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Prior Authorization Request
ColoradoPAR Program
Phone: 1-888-801-9355
5802 Benjamin Center Dr., Suite 105
Medical Review Department
Fax: 1-866-940-4288
Tampa, FL 33634
QUESTIONNAIRE #4
SEAT LIFT
Client Name:
Colorado Medicaid ID #:
Length of Need:
Height:
End Date:
Weight:
The information requested below is required to determine medical necessity. After you have completed this form,
attach it to the completed Prior Authorization Request (PAR).
1)
What is the complete diagnosis with complicating
factors:
2)
Is this request for an independent seat lift device or as
a component of a power wheelchair?
Independent Seat
Component of Power
Wheelchair Lift Device
*Note: If wheelchair component complete
Questionnaire 17.
3)
Is the seat lift mechanism intended to allow client to
perform activities of daily living independently?
Yes
No
4)
Is the client completely incapable of standing from any
chair in the home?
Yes
No
a.) If yes, is client able to ambulate independently
with or without aides (cane, walker, etc.)?
5)
What past and current equipment has been utilized?
Why isn’t the current equipment (if any) meeting the
6)
client’s needs?
7)
Please supply any additional information that will
assist us in determining medical necessity for your
request:
Print Prescriber Name
Prescriber Signature
Date
Page 1 of 1
Revision Date: 09/15
Prior Authorization Request
ColoradoPAR Program
Phone: 1-888-801-9355
5802 Benjamin Center Dr., Suite 105
Medical Review Department
Fax: 1-866-940-4288
Tampa, FL 33634
QUESTIONNAIRE #4
SEAT LIFT
Client Name:
Colorado Medicaid ID #:
Length of Need:
Height:
End Date:
Weight:
The information requested below is required to determine medical necessity. After you have completed this form,
attach it to the completed Prior Authorization Request (PAR).
1)
What is the complete diagnosis with complicating
factors:
2)
Is this request for an independent seat lift device or as
a component of a power wheelchair?
Independent Seat
Component of Power
Wheelchair Lift Device
*Note: If wheelchair component complete
Questionnaire 17.
3)
Is the seat lift mechanism intended to allow client to
perform activities of daily living independently?
Yes
No
4)
Is the client completely incapable of standing from any
chair in the home?
Yes
No
a.) If yes, is client able to ambulate independently
with or without aides (cane, walker, etc.)?
5)
What past and current equipment has been utilized?
Why isn’t the current equipment (if any) meeting the
6)
client’s needs?
7)
Please supply any additional information that will
assist us in determining medical necessity for your
request:
Print Prescriber Name
Prescriber Signature
Date
Page 1 of 1
Revision Date: 09/15