Justification Of Medical Necessity For Seating Wheeled Mobility {BWC-1317}

BWC-1317 -- JUSTIFICATION OF MEDICAL NECESSITY FOR SEATING/WHEELED MOBILITY. This form, issued by the Bureau of Workers' Compensation, is utilized to provide a justification of medical necessity for seating/wheeled mobility. It includes detailed instructions for completion, requiring the requester to print or type all information. The form must be returned to the requestor and accompany all wheeled mobility requests. It comprises five sections covering general information, medical/physical/functional status, equipment justification, equipment prescription, and evaluator details. Each section is designed to gather specific details related to the injured worker's condition, diagnosis, current equipment, requested equipment, medical history, and therapeutic objectives. Additionally, it includes fields for the evaluator's signature, credentials, contact information, and BWC ID. www.FormsWorkflow.com