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Matia Mobility Letter of Medical Necessity

MedicalNecessityForm

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

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