TX HHS Form 3706. Nursing Facility Customized Power Wheelchair (CPWC) Authorization

The TX HHS Form 3706, Nursing Facility Customized Power Wheelchair (CPWC) Authorization, is a crucial document that helps solve the problem of authorizing customized power wheelchairs for residents in nursing facilities. This form is typically used by nursing facility staff to request authorization for a resident's CPWC and provide necessary information about the resident, the facility, and the therapist involved in the assessment.

The form requires key identifying information about the resident, including their name, Medicaid number, date of birth, and legible authorized representative. Additionally, it captures details about the nursing facility, such as its name, address, and contact information. The therapist's information, including their name, title, and employer, is also essential for completing the CPWC assessment.

The form's CPWC Assessment section allows therapists to describe the resident's muscle tone, active movements affected by muscle tone, and passive movements affected by muscle tone. This information helps determine whether a customized power wheelchair is necessary for the resident's mobility and comfort. By using this form, nursing facilities can ensure that they are providing the necessary authorization and documentation for residents' CPWCs.

• This form is used to authorize customized power wheelchairs for residents in nursing facilities.
• The form requires identifying information about the resident, nursing facility, and therapist involved in the assessment.
• The CPWC Assessment section helps determine whether a customized power wheelchair is necessary for the resident's mobility and comfort.