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Indiana IHCP Motorized Wheelchair Medical Clearance

Indiana Medicaid will not review a prior authorization request for a motorized wheelchair until this medical clearance form is submitted with it. The prescribing physician documents the current chair, functional status, living situation and how the member meets coverage criteria under 405 IAC 5-19-9. The form goes with the IHCP Prior Authorization Request Form.

Who completes it

The form must be provided and signed by the prescribing physician, who answers the current chair, functional status, residence and criteria questions. The requesting provider may add an occupational or physical therapy evaluation if the answers are not sufficient for review.

Submitting and payment

How to submit it
Submit the signed form with the IHCP Prior Authorization Request Form; the request is not reviewed without it.
Who pays
The form sets no fee for the physician; it supports the prior authorization request for the motorized wheelchair.

Good to know

  • Motorized vehicles are covered only when the member attends school, a sheltered workshop or work, or is left alone for significant periods.
  • The record must show the member can safely operate the chair and lacks the upper extremity function to operate a manual wheelchair.
  • Functional status covers upper and lower extremities, hand function, contractures, neck and spine, sitting balance, ambulation, transfers, ADLs and positioning needs, each described specifically.
  • List each accessory with the member-specific problem it corrects or prevents from worsening. The current version is 3.0, October 2014; nonmotorized chairs use a separate 2015 form.

Get the official form

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

Medical Clearance Form for Motorized Wheelchair Purchase

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.

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Frequently asked questions

What are Indiana Medicaid's criteria for a motorized wheelchair?

Under 405 IAC 5-19-9, motorized vehicles require prior authorization and are covered only when the member is enrolled in school, a sheltered workshop or a work setting, or is left alone for significant periods. It must also be documented that the member can safely operate the vehicle and lacks the upper extremity function to use a manual wheelchair.

Who must sign the Indiana motorized wheelchair medical clearance form?

A prescribing physician. The form states that requests for motorized or power wheelchairs must be provided and signed by a prescribing physician to be considered for approval. A therapist's OT or PT evaluation can supplement it but does not replace the physician's signature.