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
Revised 08/29/13
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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: _________
Revised 08/29/13
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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.
Revised 08/29/13
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Below is the link to the Early Steps Policy Handbook and Operations Guide (PHOG). Please see Component 6,
Section 6.4.0.
http://www.cms-kids.com/home/resources/es_policy_0113/es_policy.html
Revised 08/29/13
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