EmpowerRide — Prescription Order Form Patient Information Patient Name: Date of Birth: Height / Weight: Diagnosis / Medical Condition: Primary Mobility Limitation: Address: Phone: Insurance Provider: Insurance ID: Prescribing Physician Information Physician Name: NPI Number: Facility / Clinic: Address: Phone / Fax: Email: Device Prescription Device EmpowerRide Navigator Pediatric Medical Mobility Device Select Medical Necessity Justification: Accessories / Custom Configurations: Length of Need: Physician Certification Physician Signature: Date: Submit
