Responsible Parties Patient Family Caregiver Manufacturer Therapist Other (Name) Rep (Name) (Name) (Name) __________ ___________ __________ _________ Therapy to address goals Initial Training Initial Customization (programming, vocab selection, intervention planning) Ongoing Training and Modification Maintenance of Device Warranty Maintenance Management NECESSARY FUNDING PAPERWORK Check when Date obtained Medicaid/Insurance Cards Copied Benefits Assignment Signed by Caregiver/Consumer Doctor’s Prescription AAC Evaluation Written Quote from Manufacturer Resources/References Consulted:
Responsible Parties Patient Family Caregiver (Name) __________ Manufacturer Rep (Name) ___________ Therapist (Name) __________ Other (Name) _________ Therapy to address goals Initial Training Initial Customization (programming, vocab selection, intervention planning) Ongoing Training and Modification Maintenance of Device Warranty Maintenance Management NECESSARY FUNDING PAPERWORK Check when obtained Date Medicaid/Insurance Cards Copied Benefits Assignment Signed by Caregiver/Consumer Doctor’s Prescription AAC Evaluation Written Quote from Manufacturer Resources/References Consulted:
ADULT-AAC-Eval-Protocol-1.docx