Mobility Code History Checklist - Amador Medical

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Client Name Client Name * First Last
Medicaid #
Power Operated Vehicle

Power Operated Vehicle K0800 K0801 K0802
Hospital Beds w/ Mattress

Hospital Beds w/ Mattress E0250 E0251 E0255 E0256 E0260 E0261 E0271 E0272 E0277 E0290 E0291 E0292 E0293 E0294 E0295 E0301 E0303 E0304 E0371 E0372 E0373
Trapeze Bar

Trapeze Bar E0910
Hoyer Lifts

Hoyer Lifts E0621 E0630
Wheelchairs

Wheelchairs K0001 K0002 K0003 K0004 K0005 K0006 K0007 K0008 K0009 K0010 K0011 K0012 E1230 K0014 E1161
Power Wheelchairs

Power Wheelchairs K0815 K0816 K0822 K0823 K0824 K0825 K0826 K0827 K0828 K0829 K0835 K0841 K0843 K0848 K0849 K0850 K0851 K0852 K0853 K0854 K0855 K0856 K0857 K0858 K0859 K0860
Complex Power Wheelchairs

Complex Power Wheelchairs K0861 K0862 K0863 K0864
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Date Date / MM / DD YYYY