Assistive Technology Assessment

Child Name______Date of Birth______

Date of Assessment ______

Part 1:Assistive Technology Assessment Team Members (IFSP Team which must include a PT, OT,SLP, or Orientation & Mobility Specialist):

Name / Initial / Role / Phone Number

Part 2:Desired Outcome(s)/Result(s) from Individualized Family Support Plan (IFSP):

______

______

______

Is it necessary to use assistive technology to accomplish the outcome(s)? Yes ____ No ____

Is assistive technology necessary to enhance the child’s current development and functioning during the time the child is eligible for and receiving early intervention services through Early Steps?

Yes _____ No _____

How will assistive technology be used to increase, maintain or improve functional capabilities of the child?

______

______

______

Part 3:Describe range of options considered (low- to high-tech).

Option/Item / Cost

List community service groups such as Lions or Elks clubs that were contacted regarding partial or total funding.

Group / Date Contacted / Response

Part 4:AT Assessment Team Recommendation(s) (Equipment being requested):

______

______

______

______

______

Part 5:Implementation Strategies

Trial period for use of assistive technology before purchase, if applicable:

______

______

______

Support and training of family members, caregivers and professionals:

______

______

______

Plan for repair and maintenance:

______

______

______

Part 6: Address where equipment is to be delivered:

______

Provider Name: ______Provider Signature: ______Date: ______

Parent Name: ______Parent Signature: ______Date: ______

Assistive Technology Process

All Assistive Technology needs must be addressed at all Individualized Family Support Plan (IFSP) Reviews. Assistive Technology requests will not be processed unless they adhere to the IFSP process including notification of the service coordinator immediately when a need is noted. Providers must consider and utilize low tech options whenever possible and will seek authorization from the child’s insurance and Medicaid, including equipment vendor information, prior to requesting payment from USF Bay Area Early Steps/Part C.

Assistive Technology Assessment Authorization (97755) will be entered once provider contacts Service Coordinator regarding equipment need.

Once the IFSP Meeting is held and IFSP outcome is created to include the need for Assistive Technology to meet the IFSP outcomes the following information must be sent to the Service Coordinator by the requesting provider to have paperwork processed:

-Completed (in full) Assistive Technology Assessment Form

-Letter of Medical Necessity

-Physician prescription for equipment

-Picture of equipment being requested

-Specific measurements and descriptions (if needed)

Upon receipt of all the required paperwork the Service Coordinator will work with the designated USF Bay Area Early Steps Program Coordinator to submit all paperwork to appropriate vendor, based on Insurance, to obtain equipment. Service Coordinator will not enter Assistive Technology Equipment code (T1999) until vendor is confirmed via requesting provider.

Service Coordinator will enter Authorization once vendor confirmed and once information received from vendor regarding payment. If partial payment made insurance remainder will be paid by Part C. Service Coordinator will enter in “Payment Information” box “The total amount to be paid from all providers is not to exceed: (Amount Part C will pay)”

Designated USF Bay Area Early Steps Program Coordinator will confirm vendor, via requesting provider, to be used and will notify the Service Coordinator, who will then enter the Assistive Technology Equipment code (T1999). Service Coordinator will need to follow up with Vendor to determine if there is a need for Part C payment on Equipment.

Below is the link to the Early Steps Policy Handbook and Operations Guide (PHOG). Please see Component 6, Section 6.4.0.

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Revised 08/29/13