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ClaimSecure Wheelchair Assessment (2002000-028A-CL)

ClaimSecure lists this form as its Wheelchair Questionnaire and asks for it when a wheelchair estimate is submitted, so the purchase or rental is assessed before approval. The physician records the diagnosis, prognosis, whether the condition is acute, chronic or palliative, how long the wheelchair is needed and, for an electric or power chair, why it is recommended.

Who completes it

The prescribing physician signs Part 3 and completes Part 4 (current medical information) in full. The claimant completes Parts 1 and 2 and the authorization, and the supplier completes Part 5 with brand, model and costs.

Submitting and payment

How to submit it
The completed form is returned to ClaimSecure with the estimate and supporting documentation by mail, fax or email.

Good to know

  • If you recommend an electric or power wheelchair, Part 4 asks you to give the reason.
  • Wheelchair benefits through ClaimSecure are supplemental to the provincial assistive devices program, and the claimant should verify provincial eligibility before applying.
  • The supplier lists the brand, model number, rental and purchase costs and attaches a cost breakdown and any provincial plan application.
  • Fields must be completed in pen using blue ink; ClaimSecure notifies the claimant in writing about coverage once all required information is assessed.

Get the official form

Download the current version from the source each time; forms change without notice.

Wheelchair Assessment Form

Official pagePDF

Fill it with Vero

Upload the fillable PDF once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

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How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms change without notice, so download the current version from the official page before you fill it in.

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Frequently asked questions

What does ClaimSecure ask the physician about a power wheelchair?

Part 4 asks for the diagnosis, prognosis, whether the condition is acute, chronic or palliative, and how long the wheelchair will be required. If you are recommending an electric or power wheelchair, you must also indicate the reason why on the form.

Is the ClaimSecure Wheelchair Questionnaire the same as the Wheelchair Assessment Form?

Yes. ClaimSecure's forms page lists it as the Wheelchair Questionnaire under specialized forms and questionnaires, while the printed form is titled Wheelchair Assessment Form, number 2002000-028A-CL. It is completed when submitting a wheelchair estimate, before approval.

Does provincial funding affect a ClaimSecure wheelchair claim?

Yes. ClaimSecure's wheelchair benefit is supplemental to services available through the provincial assistive devices program. The claimant indicates whether part of the cost will be covered provincially and explains why if not, and the supplier attaches a copy of the provincial plan application if applicable.