Illinois Medicaid uses the HFS 3701H as the letter of medical necessity for power mobility devices and custom wheelchairs. A physiatrist or physical or occupational therapist, working with a mobility device specialist, documents medical history, home, function, posture, measurements and an equipment trial, then recommends the lowest appropriate equipment. The supplier attaches it to the HFS 1409 prior approval request.
A physiatrist or PT or OT completes the evaluation with the mobility device specialist. The patient or caregiver, therapist and supplier representative sign, and the physician signs last to agree with the recommendations and order the equipment.
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Seating/Mobility Evaluation
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The final signature line on page 12 is the physician's. By signing, the physician certifies agreement with the evaluation's recommendations and orders the equipment shown on the provider's itemized price list. The therapist, supplier representative and patient or caregiver sign above it.
The form is completed by a physiatrist or a physical or occupational therapist in association with a mobility device specialist. Their names, license and contact details go on page 1, along with the suppliers for which the evaluation serves as the letter of medical necessity.