ASSISTIVE TECHNOLOGY NEEDS ASSESSMENT
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ASSISTIVE TECHNOLOGY NEEDS ASSESSMENT
Child’s Name: _________________________________ Birthdate: ____________________________
Date(s) of Eval:________________________________ Chronological Age: ____________________
Assessment Team: Parent(s): ________________________________________________________
Professional: __________________________ Professional :_______________________________
Current Equipment the child has: _______________________________________________________
Is it being used?: ___________ Where?: ________________________________________________
A. FUNCTIONAL GOAL(S):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
B. CHILD’S FUNCTIONAL ABILITIES:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
C. OBSTACLES TO GOAL ACHIEVEMENT:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
D. DISCUSSION OF LOW TECH OPTIONS -------Yes ____No _____________________________
_______________________________________________________________________________
E. EQUIPMENT TRIALS (If loaners are available):
SUMMARY OF TRIAL USAGE:
Time Period: From:______________ To:______________________
Equipment used:___________________________________________________________________________
Environments: [ ] Home [ ] Preschool [ ] Therapy Center [ ]Other:______________________________
Results: _________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
_______ ________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
______ _________________________________________________________________________________
F. PHONE CALLS TO LOCAL ASSISTIVE TECHNOLOGY SPECIALIST:
Date: _________________________________ LATS: _______________________________________
Consult recommendations: ______________________________________________________________
___________________________________________________________________________________
G. ASSISTIVE TECHNOLOGY RECOMMENDED: (consider low/high tech options): This portion is completed
With the IFSP team and includes the LATS as per policy, when needed:
1. ______________________________ Vendor: ______________________________________
2. ______________________________ Vendor: ______________________________________
3. ______________________________ Vendor: ______________________________________
*Note the vendor. **Must attach information/picture of equipment from catalog and ordering
information based on child’s insurance.
ADDRESS WHERE EQUIPMENT IS TO BE DELIVERED:
________________________________________________________________________
________________________________________________________________________
____________________________ ____________________________
Parent Parent
____________________________ ____________________________
Professional Discipline #1 Professional Discipline #2
Note at least 2 professionals from different disciplines must compromise the assessment team. An ATENS team in each area to ensure consistency in the program may review the request. This team would be comprised of therapists and one LOCAL EARLY STEPS (core) professional and the family.
LATS for Bay Area: LATS MUST BE CALLED IF EQUIPMENT IS ANTICIPATED TO BE OVER $1,000 OR IF MULTIPLE PIECES ARE NEEDED.
Independent Living: Contact is Natalie Lavallee at (813) 963-6923, ext. 226
PT: Chantel Heitler (Hills.), Vanessa Vasquez: Eileen Summers (Polk)
OT: Cindy Cooley, Sono Zaveri, Rochelle (Polk)
ST: Aleisha Linck, Patricia Falcon, Carrie Guise, Jessica Sandoval (Hills.): Tina Beasley (Polk)
Beth Ingram: Contact is Maye Oskey at (813) 653-1149, ext. 202
PT: Janice Deshiones
OT: Karen Luzcniak
ST: Gioia Harrell, Debbie Richards
Service coordinators enter the authorizations for LATS as Consultation (1 hour) and ATEN.
A). Components of the Assessment
The Components listed below should be incorporated into the needs assessment as appropriate. The components should be considered as a part of a fluid process and not necessarily sequential. The assessment should be provided in the native language or communication mode of the family and/or child, as necessary. Include LATS as part of the IFSP team and the ATEN when equipment needs address multiple concerns or if high end needs are going to be considered.
a. Assessment of the family and child’s natural environment in relation to assistive
technology needs should be completed using a variety of methods.
1. Review of the Family Assessment completed at Intake
2. Interview the family
3. Make a home visit
4. “self-assessment” tools
b. Assessment of the functional abilities and needs of the child
c. Determination of adaptations and modifications necessary to match needs and abilities.
d. Consideration of low tech and high tech options.
e. Consideration of a “skill builder” period using low-tech options.
f. Trial use period or consideration of each option deemed appropriate for the child/family.
g. Consideration of equipment flexibility and transitional capabilities.
B). Assistive Technology Needs Assessment Report
The needs assessment report must include the following
a. Child/family established outcome statement
b. Names, phone numbers and roles of assessment team members.
c. Summary of the assessment components and implementation strategies.
d. Rationale for the recommendations based on trial use data collected and expected
outcome. This should include a summary regarding other devices considered and why
they were determined to be inappropriate.
e. Pertinent purchasing information (e.g. manufacturer, cost, catalog number and picture, vendor, etc)
f. Plan to implement training for the child, family and other professionals working with
child.
h. Plan for ongoing assessment, monitoring, technical assistance, maintenance and repair.
C). Requirements for Medicaid Payment of Equipment
The items listed below are required in order for Medicaid to consider payment for assistive technology. This includes durable medical equipment, prosthetics and orthotics, and sensory devices. Medicaid does not cover furniture (this does not mean adaptive chairs, etc. which should be requested of Medicaid), physical fitness equipment, and training and self-help equipment.
a. All requests for a child with Medicaid must be sent to Medicaid through purchase order from IYC to seek approval for Medicaid. These are coordinated by the service coordinator.
b. These requests must include a physician prescription obtained by the therapist.
c. They must include a letter of medical necessity written by the therapist or the physician.
d. A prior authorization must be included (note the code is E 1399 which is a miscellaneous equipment request). The prior authorization form is found on the following webpage:
There is a sample form that you can review on the ACS website.
D). Requirements for Part C Payment of Equipment
The items listed below are required in order for Part C to pay for assistive technology. This includes durable medical equipment, prosthetics and orthotics, and sensory devices. IYC has equipment delivered to the providers and providers tag the equipment as Lending Library and notifies IYC.
i. FSPSA noting the equipment and payer source
ii. EOB or denied PA either from the third party insurance or from Medicaid IYC receives this from the vendor.
iii. Prescription for the equipment
iv. Letter of medical necessity
v. ATEN report
vi. Picture of equipment & preferred catalog
vii. Page F, outcome page listing assistive technology strategy (service page summary desired also)
E) Procedure for Assistive Technology Trial Follow-up
• Page F of IFSP: an outcome page for equipment must be updated at each IFSP meeting.
Companies that accept Third Party Insurance and Medicaid
All equipment requests need: Letter of Medical Necessity, prescription, Insurance/Medicaid Authorization, FSPSA, ATEN Report, picture of equipment & preferred catalog
All Children’s Provide DAFOs and splints-they invoice Medicaid and TPIN
Bay Care Homecare Invoices General Medical Insurance, they need copy front and back of
the insurance card (need name of Policy holder) They work with
multiple insurance companies.
Example of Equipment they provide:
Durable Medical Equipment such as Walkers, Bath chairs, Feeding
Seats, Standers, Kid Karts, positioning devices, etc.
Custom Medical Invoices General Medical & Insurance & Medicaid Waiver programs.
They need copy front and back of the card (also Policy holder name) They
work with multiple insurance companies.
Example of Equipment they provide:
Durable Medical Equipment such as Walkers, Bath chairs, Feeding
Seats, Standers, Kid Karts, positioning devices, etc.
They Invoice Requests for IYC for the following companies:
Companies-Sammons, Rifton, Theraadapt, Abilitations (as these
companies do not invoice Medicaid or TPIN) So the company on the
FSPSA should be the DME provider with a note in the comment box
of the specific catalog (eg. Sammons Preston) for Medicaid or TPIN.
(The specific vendor per catalog can be used if Part C has been
determined to be the payer.)
Custom Mobility Invoices General Medical & Insurance & Medicaid Waiver programs.
They need copy front and back of the card (also Policy holder name)
They work with multiple insurance companies.
Example of Equipment they provide:
Durable Medical Equipment such as Walkers, Bath chairs, Feeding
Seats, Standers, Kid Karts, positioning devices, etc.
They Invoice Requests for IYC for the following companies:
Sammons, Rifton, Theraadapt, Abilitations (as these companies do not
invoice Medicaid or TPIN) So the company on the FSPSA should be the
DME provider with a note in the comment box of the specific catalog (eg.
Sammons Preston) for Medicaid or TPIN.
(The specific vendor per catalog can be used if Part C has been
determined to be the payer.)
Hanger Orthopedic They invoice all major insurance, Medicaid and HMO’s
They provide some Durable Medical Equipment, Prosthetics and
Orthotics (AFOS, DAFOs, hand splints, etc.)
PTS-Brandon-Lakeland They invoice Medicaid and most TPIN
They provide AFO’s, DAFOS, hand splints
West Coast Invoices All Medicaid, Cigna, Aetna (just added recently), BC/BS.
Provides any type of brace for the body, (not durable equipment)
Equipment, Prosthetics and Orthotics (AFOS, DAFOs, hand splints, etc.)
Will vend services for Sammons-Prseton, Benik
Shriner’s Hospital Will cover children who have orthopedic needs if the child has a
sponsor. Call Beth Demas at Shriner’s to see how this can
be arranged. They work with CMS for children who need
wheelchairs.
*For Individual Therapy Providers that do AFO’s, Splints, etc., please see the provider insurance list to see what insurances, Medicaid is accepted. This is only a partial list and the service coordinator needs to call the company if not on this list to see which insurance or Medicaid is accepted.
Abilitations: Part C only**** Ablennet: Part C only
Achievement: Part C only
American Discount: Part C only
Beyond Play: Part C only
Cascade DAFO: Part C only
Enabling Devices: Part C only
Flaghouse: Part C only
Hip Helper: Part C only
Kaplan: Part C only (discount to IYC)
Lakeshore: Part C only
Sammon’s – Preston: Part C only (discount to IYC)****
Rifton: Part C only ****
Benik: Part C only****
Snug Seat: Part C only
Theraadapt: Part C only
****(If the child has Medicaid or TPIN) must enter under Custom Mobility or Custom Medical. Send a picture and preferred vendor and IYC will use this in the purchase order to these major providers of durable medical equipment. WE know they work with the specific vendors that are starred to invoice Medicaid or TPIN as the individual vendor will not do
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