| 1.
Has AAC assessment been completed pursuant to the DMERC
RMRP outline? |
Yes
No
|
| 2. Have
appropriate device or AAC software to meet the individual's
daily functional communication needs been identified and
specified? |
Yes
No
|
| 3. Have necessary
AAC device accessories been identified and specified? |
Yes
No
|
| 4. Is recommended
device and accessories are covered by Medicare? |
Yes
No
|
| 5. Does manufacturer/supplier
of the recommended device and accessories accept Medicare
assignment? |
Yes
No
|
| 6. Has clinician
discussed equipment costs with client and/or family? (Particularly
important if the device is not covered, or no assignment
will be taken.) |
Yes
No
|
| 7. Has an
alternative device been identified if the recommended
device is not affordable? |
Yes
No
|
|
8. Has the written report been completed
pursuant to the DMERC RMRP outline that it:
a) supports recommendation of the AAC device, AAC software,
and each AAC accessory;
b) identifies the SLP who will provide setup and training
services (if different from SLP conducting assessment);
and
c) describes treatment plan for training and services
needed to achieve listed functional goals:
|
Yes
No
|
| 9. Has the
written report been forwarded to individual's treating
doctor for review so physician can prescribe all recommended
items? |
Yes
No
|
| 10. Has the
beneficiary and family been informed how to contact manufacturer/supplier
of AAC device to obtain the device and process the Medicare
claim? |
Yes
No
|
| 11. Has the
beneficiary and family been informed to contact SLP who
will provide set up and training services after delivery
of AAC device, AAC software and/or accessories? |
Yes
No
|
