All medicaid recipients, including all home and community-based care (HCBC) waiver recipients and recipients residing in nursing facilities, shall be eligible to receive wheelchair van services, in accordance with this part, when:

1. (a) The recipient is confined to a wheelchair for mobility, which means:

   1. (1) At the time of a wheelchair van service, the recipient is unable to ambulate without the use of a wheelchair; and
   2. (2) The recipient is unable to be transported in a private vehicle without special equipment or modifications to the vehicle; and
2. (b) The wheelchair van services are required as certified on Form 975 “Documentation to Support the Use of Wheelchair Van Services” (May 2014) by the signature of the recipient’s treating physician, physician assistant (PA), advanced practice registered nurse (APRN), or registered nurse (RN).

Source. (See Revision Note at chapter heading He-W 500); ss by #6598, eff 10-8-97; ss by #8401, INTERIM, eff 8-20-05, EXPIRES: 2-16-06; ss by #8563, eff 2-7-06; ss by #10605, eff 5-23-14