D9379 - Electric Mobility Aids - Part 3 - Trial

Form ID
D9379
Audience
For providers
Occupational therapist (general)

This trial form is to be completed by the Occupational Therapist (OT) for Rehabilitation Appliances Program (RAP) electric mobility aids (electric mobility scooters, electric wheelchairs, power assist devices and carer-operated wheelchairs).

This is part 3 of a 3-part process (see D9300 for part 1 and D1325 for part 2).

If you are using an Apple computer and want to fill out your form electronically, please download the form and open it with Acrobat 7 or later.

How can I access this form?
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Form (PDF or Word)