Wheeled Mobility Seating Evaluation Form

Do you need a combination assessment and justification for your wheelchair and seating evaluation? This form provides a fillable PDF for use in the clinic.

The Wheeled Mobility and Seating Evaluation tool, commonly used by many therapists, has been updated for 2024 by Julie Piriano, Jill Sparacio, and Jessica Presperin Pedersen. This new version includes enhanced evaluation and justification details based on peer-reviewed research, supports innovative product designs, and addresses third-party payor denials. It also clearly outlines areas that may be completed by the supplier ATP as part of the team-based evaluation process. In addition, new clinician and supplier attestations have been added to confirm that improper practices, such as scribing, have not occurred. For any questions, please contact the EIM team at EIM@sunmed.com.

Sparacio and Presperin Pedersen expanded this evaluation to follow the process of what a therapist must consider when recommending equipment. They reviewed all the paragraphs pertaining to justification of each product quote and created a checklist of justification statements in a product flow from mobility base with all the components on a wheelchair followed by seating products. This form allowed therapists and third-party payers the opportunity to follow a step-by-step process for evaluation which paints a clear picture of the physical, functional, environmental, and participatory information pertaining to the patient/rider. The recommendation and justification of the equipment immediately follows.

After a trial period at Misericordia and the Rehabilitation Institute of Chicago, it was mandated by the state of Illinois for anyone seeking Medicaid reimbursement for wheelchairs. Several versions have been implemented since then and similar forms can be found on NRRTS, AOTA, and various supplier websites. It has been translated into several languages. Feel free to download it and add logos depicting the facility you work for. It has never been copyrighted so that Sparacio and Presperin Pedersen could share it for anyone's use. Please continue to credit the authors listed at the bottom.