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Matia Mobility Letter of Medical Necessity


Provider Information

Patient Information

Device Information

Item: (E0884) Tek RMD M1 Power Wheelchair Grp 4 

Accessories: (E2300) Power Seat Elevation System

                        (E2301) Power Standing System

                        (K0108) Control System Remote

                        (E0953) Lateral Knee Supports

                        (E2363) Group 24 Batteries

                        (E6021) Seat Sling Adjustable

                        (K0844) Outdoor Wheel Conversion

Letter of Medical Necessity

Please review and edit the patient specific information below. Please make any edits you feel are warranted for the patient. When you are done editing, please press the SUBMIT FORM button at the bottom. Thank you.