EmpowerRide™ Navigator
Letter of Medical Necessity (LMN) Download
For Physicians, Physical Therapists (PTs)
& Occupational Therapists (OTs)
To support clinical documentation and insurance authorization, EmpowerRide provides a standardized Letter of Medical Necessity (LMN) template for the EmpowerRide Navigator™ Pediatric Medical Mobility Device. This downloadable form is designed to assist physicians and rehabilitation professionals in documenting medical diagnosis, functional limitations, previous equipment trials, and clinical justification for caregiver-assisted mobility support.
The template aligns with common reimbursement requirements and facilitates clear documentation of medical necessity, positioning needs, safety considerations, and expected functional outcomes. Providers
may complete and submit this form as part of the patient’s funding or authorization process.