Rehabilitation establishments use this six-page French form to justify a manual or power wheelchair, positioning base, adapted stroller or posture aid under RAMQ's program for devices that compensate for a physical deficiency. An occupational therapist or physiotherapist documents a full functional evaluation and intervention plan. The authorized prescribing physician co-signs, and the establishment's technical aids service supplies the device.
The occupational therapist or physiotherapist completes the request (aids requested, nature of the request, eligibility, justification) and the functional evaluation, attesting that the person is eligible and needs the aid. The authorized prescribing physician signs Section 8 with their name and professional number.
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Attestation du besoin d'une aide à la locomotion ou à la posture
Certification of Need for a Mobility or Posture Aid
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Two people: the occupational therapist or physiotherapist who did the functional evaluation, attesting that the person is eligible for the program and needs the requested aid, and the authorized prescribing physician, who signs Section 8 with their name in block letters and professional number.
Manual wheelchairs, power wheelchairs, positioning bases, adapted strollers and posture aids, including special consideration (C.S.) devices or components. The request can be an initial supply, an additional device or a replacement; for a replacement, the form records the date of possession and model of the device being replaced, and the reason.
Section 4 asks whether the person lives in a public or subsidized private (conventionné) establishment and, if so, whether they have special needs that a standard manual wheelchair cannot meet. The answer forms part of the eligibility section completed by the therapist.