Every request for a wheelchair, power mobility device or seating system in an Ohio BWC claim must include this justification. A physician or evaluating physical or occupational therapist documents the diagnosis, the problem with current equipment, the worker's physical and functional status, and a specific equipment prescription. The completed form goes back to whoever is requesting the equipment so it can accompany the request to the managed care organization.
The prescribing physician or the evaluating PT or OT completes the sections that apply and signs Section V with credentials, license, NPI and BWC ID. A standard wheelchair needs only Sections I and V.
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Justification of Medical Necessity for Seating/Wheeled Mobility
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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Only Section I (general information) and Section V (evaluator) are required for a standard wheelchair. A specially sized or constructed chair, custom molded seating, adaptive positioning devices, a power wheelchair or a three-wheeled vehicle needs all five sections, including the medical status, justification and equipment prescription.
Yes. Section V lets the evaluator mark credentials as physician, physical therapist or occupational therapist and enter a license number, NPI and BWC ID. The evaluator signs and prints a name, so the therapist who performed the seating evaluation can complete it.