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Vermont DVHA Complex Wheelchair Positioning Evaluation

Vermont Medicaid uses this evaluation and prescription form when a member needs a complex manual or power wheelchair. The evaluating therapist documents function, medical status, transportation, the home environment, measurements and a successful trial, then prescribes each component with a medical necessity justification. A cost comparison shows why less expensive devices were considered and ruled out.

Who completes it

The evaluating physical or occupational therapist completes the form, including the date the referring provider first requested the wheelchair evaluation. The prescribing practitioner is part of the request that goes to DVHA.

Submitting and payment

How to submit it
Send it with the Uniform Medical Prior Authorization Form to the DVHA Clinical Unit. DVHA posts it as a Word document, so it is typed and saved rather than downloaded as a PDF.

Good to know

  • A successful trial of the requested device and the referral date are both required; missing documentation delays medical necessity review and can lead to administrative denial.
  • The cost comparison must address walker or cane, manual chair, lesser manual chair, scooter, power assist and lesser group power chair, citing Medicaid Rule 7102.2.
  • Some items apply only by age: the MRADL checkboxes and the home suitability question are for members over 21, school and community terrain for members under 21.
  • Home visits by the prescribing therapist, in person or by telemedicine, are strongly recommended to confirm the device suits the home environment.

Get the official form

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

Wheelchair Form: Positioning Evaluation and Prescription Form

Official pageWord file

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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

Which Vermont form is used for a complex wheelchair?

DVHA's Wheelchair Positioning Evaluation and Prescription Form for Complex Wheelchairs, updated September 2025. Basic and rental manual wheelchairs use a separate DVHA evaluation and prescription form. Both are Word documents on DVHA's clinical prior authorization forms page and are sent with the Uniform Medical Prior Authorization Form.

Is a home visit required for a Vermont complex wheelchair evaluation?

The form strongly recommends a home visit by the prescribing therapist, in person or through telemedicine, to make sure the device works where mobility-related daily activities happen. It still asks for home details such as entry, ramp slope, door widths, threshold height and turning radius.

What does the cost comparison section require?

Vermont Medicaid covers the least expensive medically appropriate device under Medicaid Rule 7102.2. The evaluator documents that each alternative was considered or trialed and gives a reason it is not appropriate: walker, cane or crutches, manual wheelchair, a lesser manual chair, a scooter, power assist and a lower-group power wheelchair.