AUGMENTATIVE COMMUNICATION EVALUATION Medicaid Reimbursement

AUGMENTATIVE COMMUNICATION EVALUATION

Medicaid Reimbursement

Evaluation Date(s):

Client Information:
Name:	Medicaid ID#:
Medical Diagnosis:
Ethnicity:
Languages Spoken/Understood:
Residence:
Speech-Language Diagnosis:
History of Speech and Language Treatment:

Evaluative Team Information:
Family Member/Primary Support Person:	Phone:
Speech-language Pathologist:	Phone:
Physical Therapist:	Phone:
Occupational Therapist:	Phone:
Case Manager:	Phone:
Primary Care Physician:	Phone:
Educator:	Phone:
Aide/Paraprofessional:	Phone:
Additional Team Members:	Phone:

Prescription for AAC Evaluation & Equipment:
The speech-language pathologist with current licensure and expertise in augmentative communication has determined that (individual)'s ability to communicate using natural speech and writing interferes with (his/her) meaningful participation in current and projected daily activities. An electronic system has been determined to be medically necessary and serve diagnostic and therapeutic purposes. Through the use of an AAC system, (individual) can meet the goal of restoring functional communication ability to the maximum degree possible.

ASSESSMENT RESULTS

Physical Status:

Pertinent Medical Considerations:

Hearing:

Vision:

Tactile:

Mobility Status:

Head Control:

Trunk Stability:

Arm/Hand Movement:

Isolated Finger Movement:

Muscle Tone/Movement:

Current Communication Abilities:

Cognitive Status:

Current Means of Communication:

Comprehension/Receptive Language:

Interaction Ability:

Oral Motor Ability:

Articulation/Speech Status:

Prognosis for Further Speech Development:

Reading/Writing/Spelling Abilities:

Names and Scores of Standardized Tests:

Emotional Adjustment as it Relates to Communication:

Communication Needs Assessment

(Individual) needs an augmentative communication system that will meet the following needs (Check all that apply):

Communication System: ___verbal ___written

Communication Partners: ___familiar listener's ___unfamiliar listeners
___Groups

Symbols: ___picture-based ___orthographic

Encoding: ___abbreviation expansion ___Word prediction ___dynamic display
___levels ___semantic compaction

Vocabulary: ___pre-stored messages ___self-generated/novel vocabulary
___Medical/emergency

Independent Living Needs: ___Environmental controls ___basic functions

Communication Positioning: ___seated ___lying down ___mounted
___portable ___carrying case

Limitations of Current Communication System in Meeting the Above Needs

System Access

Seating/Position for Use of Device:

Ability to Access Device Reliably:

Rationale and Criteria for Selection of Prescribed System

AAC systems considered:

Data and Observations on AAC Systems Tried:
Include description of device, accuracy of symbol use, accuracy of motor access, overlay configuration (type, number, size and arrangement of symbols used), individual's personal preferences, and any other discriminating observations.

Rationale for selection of specific system:
Include device specifications, benefits to user over other systems considered indications for success and independence with selected device, cost effectiveness of selected system.

Prescribed Augmentative Communication System
Describe recommended AAC system and provide justification of costs

System Name	Description	Vendor	Cost
Device:
Interface:
Device Accessories:
Mounts:
Software:
Environmental Controls:
Shipping and Handling:
Training Costs:
Total Cost:

Treatment Plan and Follow-Up

Include recommended amount of training, who needs to be trained, how the plan will be implemented, and any support necessary that will ensure client success.

Treatment Goals Person Responsible
1.
2.

Signatures

cc: