Exhibit B

SPECIALTY / CUSTOM WHEELCHAIRS

Wheelchairs that have been measured, fitted, or adapted by a certified specialist known as an ATS (Assistive Technology Specialist) in consideration of an individual memberís disability and including customized features, modifications or components in accordance with instructions from the patientís physician. Customized features include, but are not limited to, postural control devices, custom molded cushions and inserts or lateral supports. Members requiring these wheelchairs should be totally nonambulatory and have severe weakness of the upper extremities.

 

Facility: _________________________________ Date: ________________

 

Signature: _______________________________ Title: ________________________