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Georgia Medicaid CMN for Power Wheelchair

Georgia Medicaid requires this three-page certificate, with a PT or OT evaluation, before authorizing a power wheelchair. The physician documents a mobility-focused physical examination and explains why a manual wheelchair with the same options will not meet the member's needs. The DME supplier submits it with the prior authorization request.

Who completes it

The ordering physician completes the examination findings and rationale and signs. The PT or OT who performed the evaluation signs with their Georgia license number, and the NRRTS-member supplier who assessed the member and recommended the equipment signs as well.

Submitting and payment

How to submit it
The DME supplier submits the completed certificate with its prior authorization request to Georgia Medicaid, attaching a copy of the NRRTS member's license or certification.
Who pays
The form sets no fee for the physician; it supports the supplier's prior authorization for the power wheelchair.

Good to know

  • The exam section covers ambulation, ability to self-propel, cognition, endurance, head and neck control, trunk, pelvis and hips, upper and lower extremities, and skin integrity.
  • The physician certifies a face-to-face evaluation about the device within 10 months, defined as 304 days, before the order.
  • The form asks whether a home environmental assessment was done and whether the home has room to maneuver the device on a flat, level surface.
  • It asks whether the member received a custom manual or power wheelchair in the last 5 years (over 21) or 3 to 5 years (under 21). Stamps are not accepted.

Get the official form

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

Certification of Medical Necessity for Power Wheelchair

Official pagePDF

Fill it with Vero

If your copy of the form is a fillable PDF, upload it 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 and their requirements change without notice, so check the official page for the current version before you complete one.

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

Who signs Georgia's power wheelchair CMN?

Three people sign: the ordering physician, who certifies medical necessity and a face-to-face evaluation within ten months; the physical or occupational therapist who evaluated the member, with Georgia license number and expiration; and the NRRTS-member supplier who assessed the member and made the equipment recommendations in collaboration with them.

What justification does Georgia Medicaid want for a power wheelchair?

A detailed rationale explaining why a manual wheelchair with the same options and accessories will not meet the member's needs, plus justification for power tilt or recline if requested. For the base and each accessory, the form asks why it was chosen and why any less costly alternative was not appropriate.