NORTH CENTRAL EARLY STEPS
ASSISTIVE TECHNOLOGY GUIDELINES AND
PROCEDURES MANUAL
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UF College of Medicine Department of Pediatrics North Central Early Steps
April 23, 2012
S ection 1:
Over view of Assistive Technology in
E a r l y I n t e r ve n t i o n
PURPOSE AND DEFINITION OF ASSISTIVE TECHNOLOGY IN EARLY INTERVENTION
WHAT IS THE DIFFERENCE BETWEEN HIGH-TECH AND LOW-TECH ASSISTIVE TECHNOLOGY DEVICES?
WHAT IS THE DIFFERENCE BETWEEN AN ADAPTATION AND AN ASSISTIVE TECHNOLOGY DEVICE?
ASSISTIVE TECHNOLOGY DEVICES AND LIMITATIONS
Purpose of Assistive Technology
Assistive Technology, or AT, refers to adapting a child’s environment in order to support his/her ability to
participate actively in the home, childcare program, or other community settings. This may include the ability
to play successfully with toys and other children, communicate needs and ideas, make choices, and move
independently.
For young children, this often involves low tech adaptations such as helping a child to sit by building support
into their highchair with towels, modifying their spoon by increasing the size of the handle, making a book
easier to look at by putting spacers between the pages, or helping a child feel an object they cannot see by
adding texture to the object. It can also include more sophisticated technology such as communication or
mobility devices.
Definition of Assistive Technology
The definition of assistive technology includes both assistive technology devices and assistive technology
services.
Assistive technology devices are identified in the Individuals with Disabilities Education Act (IDEA 2004) as:
Any item, piece of equipment or product system, whether acquired commercially off the shelf,
modified, or customized, that is used to increase, maintain, or improve the functional capabilities of
children with disabilities. The term does not include a medical device that is surgically implanted, or
the replacement of such device. (Authority 20 U.S.C. 1401(1))
An assistive technology service means any service that directly assists a child with a disability in the
selection, acquisition, or use of an assistive technology device.
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UF College of Medicine Department of Pediatrics North Central Early Steps
April 23, 2012
What is the Difference Between High-Tech and Low-Tech AT Devices ?
High- and low-tech are terms used to describe AT devices. These terms describe devices that range from
simple (low-tech) to more complex (high-tech) devices. Low-tech AT devices involve the use of simple external
materials to allow the child to perform tasks and participate in activities and can be purchased or made using
simple hand tools and easy to find materials. Low-tech devices may include objects/symbols/pictures mounted
on a communication board, feeding utensils, switch-activated toys, or dycem to keep a bowl from slipping.
Low-tech devices are usually inexpensive, often homemade, and may generally be operated “out of the box”
without much modification or training. High-tech devices are specialized and are usually marketed through
specialized catalogues that are generally distributed to professionals. High-tech devices may be expensive,
complex to operate, and may require specific knowledge and training to make appropriate selection decisions
and to allow effective ongoing use.
AT services must be directly relevant to the developmental needs of the child and specifically excludes devices
and services that are necessary to treat or control a medical condition or assist a parent or caregiver with a
disability. Equipment/devices must be developmentally and age appropriate to be considered eligible for
funding.
What is the Difference between an Adaptation and an AT Device?
Adaptations and AT both represent interventions that may be used to enable a child to participate and learn
successfully. AT devices refer to items, products, or equipment such as equipment used to position a child with
a disability (e.g., standing frame; adapted seating) or items such as toys, communication devices, or eating
utensils. Adaptations are broader than but encompass AT devices are include environmental modifications
made to address situations in a child’s environment. For example, when a childcare teacher re-arranges a
classroom (e.g., room arrangement) so that a child who is in a wheelchair can get around easily, the
environment has been adapted to promote independence. When a parent uses sign language to communicate
with a child, this is an example of an adaptation in activity requirement but not an example of AT. Knowing the
exact differences between AT devices and the broader group of adaptations is not important. What is
important is recognizing that both adaptations and AT may promote children’s participation and learning in
everyday activities and routines.
Assistive Technology Limitations
Certain equipment/services are not covered under the scope of AT and payment will not be made for its provision. The
following are examples of devices or services that are not considered AT under the Early Steps Program.
Equipment/services that are prescribed by a physician, primarily medical in nature and not directly related to a child’s
developmental needs.
o Examples include but are not limited to helmets, oxygen, feeding pumps, heart monitors, apnea
monitors, intravenous supplies, electrical stimulation units, beds, etc.
Assistive technology device must be ordered well in advance of the child's third birthday to ensure that the item will
be available in time for the child/family to benefit from other early intervention services.
Equipment/services for which developmental necessity is not clearly established.
Equipment/services covered by another agency.
Equipment/services where prior approval has not been obtained.
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UF College of Medicine Department of Pediatrics North Central Early Steps
April 23, 2012
Typical equipment, materials, and supplies related to infants and toddlers utilized by all children and which require no
special adaptation. Examples include clothing, diapers, cribs, high chairs, car seats, infant swings, typical baby/toddler
bottles, cups, utensils, dishes, infant monitors, etc.
Toys that are not adapted, used by all children and are not specifically designed to increase, maintain, or improve the
functional capabilities of children with disabilities include such examples as building blocks, dolls, puzzles, balls, ball pits,
tents, tunnels and other common play materials.
Standard equipment used by service providers in the provision of early intervention services (regardless of service
delivery setting), such as therapy mats, tables, desks, etc.
Equipment/services that are considered duplicative in nature, generally promoting the same goal and/or objective with
current or previously approved equipment/services.
Equipment/service if a less expensive item or service is available and appropriate to meet the child’s need.
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UF College of Medicine Department of Pediatrics North Central Early Steps
April 23, 2012
S ection 2:
Assistive Technology Assessment Guidelines
EARLY INTERVENTION ASSISTIVE TECHNOLOGY PRINCIPLES
CRITICAL AREAS TO CONSIDER WHEN DEVELOPING AN ASSISTIVE TECHNOLOGY PLAN
Early Intervention Assistive Technology Principles
The following are principles to consider when assessing the potential for AT
solutions:
Principle 1:
Families are involved in developing and implementing AT devices for
their child.
Principle 2:
AT devices are infused in the child’s daily routines across home,
childcare and other settings and is a strategy to foster learning and
independence.
Principle 3:
AT assessment and intervention is addressed in a team-based
collaborative manner with the family as an integral member of the
decision-making team.
Principle 4:
AT focus is on function – “What is it that the child needs to do that
he/she currently cannot do?”
Principle 5:
Strive for simplicity. AT tools are easy to use and can be adapted to
the environments of the child and family.
Principle 6:
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AT assessment should be addressed during the development of the
IFSP when there is reason to believe the child would benefit from
the use of an AT device.
UF College of Medicine Department of Pediatrics North Central Early Steps
Early Steps Policy and Guidance
Documents
The assistive technology assessment
is recommended and conducted by
the IFSP team and should not occur
outside of the IFSP process.
(PHOG Policy 6.4.1, 6.4.2)
The assistive technology assessment
must be completed prior to the
purchase of the equipment by the
IFSP “TEAM” (PHOG Policy 6.4.1)
The IFSP team must include at least
one of the following for children
needing an assistive technology
assessment: audiologist, LATS, OT,
Orientation and Mobility Specialist, PT,
SLP (PHOG Policy 6.4.3).
Recommendations should not be
driven by Technology and should
consider the use of low-cost
alternatives. (PHOG 6.4.4, Guidance)
Hearing aids and (frequency
modulation) FM systems are
recommended by the audiologist.
(PHOG 6.4.6 guidance)
April 23, 2012
Critical Areas to Consider When Assessing the Need for an AT Device
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UF College of Medicine Department of Pediatrics North Central Early Steps
April 23, 2012
S ection 3:
Procedures for Acquisition of Assistive
Technology
PAYMENT CONSIDERATIONS OF ASSISTIVE TECHNOLOGY
ASSISTIVE TECHNOLOGY ASSESSMENT PROCESS
STEPS TO OBTAINING ASSISTIVE TECHNOLOGY
CMS EARLY STEPS PAYING FOR AMPLIFICATION FOR CHILDREN WITH HEARING LOSS
RESOURCES AND APPENDIX
Payment Considerations of Assistive Technology
The IFSP team must follow Medicaid’s durable medical equipment requirements when purchasing assistive
technology devices.
All assistive technology devices must be purchased through the local CMS area office
unless:
The item is billable to Medicaid or private insurance; or
The item is less expensive if purchasing directly from the manufacturer.
Individuals with Disabilities Education Act (IDEA), Part C funds shall not be used
to satisfy a financial commitment for services that would otherwise have been
paid for from another public or private source.
Medicaid and TPIN and loaners FIRST
Early Steps Policy and
Guidance Documents
The IFSP should order
assistive technology devices
well in advance of the child’s
third birthday to ensure that
the item will be available in
time for the child/family to
benefit from other early
intervention services which
end by age three.
(PHOG 6.4.8, guidance)
North Central Early Steps and CMS work together for equipment covered by
Medicaid.
North Central Early Steps maintains the right to request the substitution of a less
expensive item of comparable function if a substitution is deemed appropriate.
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UF College of Medicine Department of Pediatrics North Central Early Steps
April 23, 2012
Assistive Technology Process
Steps 1 and 2 to be completed prior to submission for request for an AT device:
1ST STEP - REFERRAL
A referral for an AT Assessment may be made at any time. It is preferred that
the team evaluating child for eligibility to NCES consider and document the
need for an AT assessment.
2ND STEP – AT ASSESSMENT:
Once a referral is received, the Servicer Coordinator contacts team
members to determine what members to include, when and where to do
the assessment and the amount of time that will be required. The team
will also discuss the types of technology that may be needed during the
assessment. Ideally, the assessment is done in the individual's own
environment. This allows the team to identify the strengths and needs in
the actual environment where the devices will be used.
Early Steps Policy and
Guidance Documents
Equipment is purchased
through the local CMS office
or through agreement
between the LES and local
CMS to ensure CMS
negotiated vendor rates, 80%
of cost to general public
(PHOG Policy 6.4.5)
Equipment is not ordered
directly from a vendor
UNLESS it is less costly than
ordering through CMS and
must follow your LES
procedures. (PHOG Policy
6.4.6)
Information collected during the assessment process should include:
o Documentation of child’s strengths and weakness, AT device
tried with the child and family, including low and high tech
devices.
o If AT device is warranted:
o A description of the specific AT device needed.
o The methods and strategies for use of the AT device to increase,
maintain, or improve the child’s functional capabilities, the individuals
(including parents, other caregivers and family members, and qualified
personnel) who will be assisting the child in using the device, and the settings in which the
device is to be used.
3RD STEP –REQUIRED DOCUMENTATION :
The following documents are to be completed by the provider and or team requesting the AT
device and/or service:
 AT Activity-Based Provider Assessment Form (Please refer to Appendix A of this manual.)
 North Central Early Steps Assistive Technology Prior Approval Request Form (Please refer to
Appendix B of his manual.)
o If TPIN or Medicaid did not provide support for device and/or service, attach a copy
of the denial letter
 Physician’s Authorization (Must be written within the previous six month time frame)
 Separate letter of developmental necessity from a credentialed evaluator is required. The
letter must be dated within the recent six-month time frame and include information on the
child’s developmental need and current functioning level. Note: Do not include AT
justification in the initial evaluations or assessments. A recommendation to complete an
evaluation to determine the need for AT must be made by the IFSP team prior to the
development of a letter of developmental necessity;
 Copy of Vendor Quote including options/accessories breakdown
 Picture and description of item including manufacturer pricing
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UF College of Medicine Department of Pediatrics North Central Early Steps
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4TH S TEP - RESPONSIBILITY OF AT COORDINATOR :
AT coordinator to review documentation to ensure that all needed paperwork for processing is
complete and up-to-date.
o
If missing or additional information is required, a memo of notification identifying what
information is needed will be provided to the child’s Service Coordinator. The Service
Coordinator will have 5 working days to obtain needed documentation for processing. If
information is not received by this time, request will be denied due to lack of information.
o
Once all pertinent information is received to the satisfaction of the AT Notification of Request
Form will be provided to Service Coordinator (Please refer to Appendix C of his manual.)
5TH STEP – RESPONSIBILITY OF SERVICE COORDINATOR :
The Service Coordinator enters into the Early Steps Data Base an authorization for any approved
items. The information for the authorization must be entered exactly as written in the Notification of
Request Status form, noting DME codes, amount and funding source , and must be checked for
accuracy prior to saving the authorization in the Early Steps data base.
Once the request has been authorized in the Early Steps data base the Ser vice Coordinator
provides the AT Notification of Request Form to service provider/agency if item is being
purchased through them.
NCES agrees to purchase an item; all supporting documentation will be provided to NCES fiscal
support staff, in compliance with all UF fiscal/accounting policies and procedures. Payment will
be made to vendor using the departmental UF P-card or by processing a voucher, preferably
after the equipment has been physically received. If required, a purchase order will be set up t o
initiate the purchase of AT.
MANAGEMENT OF AT WILL BE DONE IN COMPLIANCE WITH UF’S ASSET MANAGEMENT AND
ATTRACTIVE ITEMS DIRECTIVES
Once the order has been placed, delivery of the equipment will be made in coordination with
NCES fiscal staff, service coordinator, Service Provider and the family/guardian. For practical
purposes, equipment can be shipped directly to the family, rather than to NCES administrative
offices. In this case, the Service Coordinator and the family/guardian of the child shal l
acknowledge, in writing, receipt of such equipment. The signed document shall be returned to
fiscal staff for fiscal accountability in the appropriate files.
IF THERE IS A CHANGE IN DME CODES
At times, especially with orthotic requests, the vendor will quote the orthotics based on the
therapist’s letter of developmental necessity. When the vendor sees the child, it may be necessary to
change the code(s) originally requested.
If this occurs:
 Complete a new AT request form with the new information. Write “code change” at the
top of the page.
 Obtain a new vendor quote and manufacturer’s pricing information (not required for
Orthotics).
 Obtain a new physician script if the script states specific items that are no longer
applicable.
Provide the above information to the AT Coordinator.
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UF College of Medicine Department of Pediatrics North Central Early Steps
April 23, 2012
IF A.T. EQUIPMENT IS NO LONGER IN USE, DAMAGED OR LOST/STOLEN
If for some reason the AT equipment is no longer in use because child no longer has a need for
it or has outgrown the equipment, the device shall be returned to NCES in order to be assigned
in the future to another child, or be made available to another Local Early Steps or organization.
If the equipment is not in a working condition and it would not be feasible for re -assignment, a
form will be filled out and the equipment disposed of, in accordance with UF’s fiscal and asset
management policies and procedures.
If the AT equipment has been lost or stolen, the Service Provider and/or Service Coordinator
shall inform NCES fiscal staff, who will complete required paperwork, in accordance with UF
Accounting and Asset Management policies and procedures
RETURNS AND OR REPLACEMENTS OF AT DEVICE
If an item is received by the family and is determined by the therapist not to appropriately meet the
child’s needs, the item is to be returned so that appropriate equipment can be obtained.
The Service Provider contacts the Service Coordinator about equipment return.
Equipment in question is returned to the vendor by the NCES Fiscal Support staff in accordance with
vendor and UF policies and procedures.
If a replacement item is needed, the Service Coordinator obtains the following information:
 Revised NCES Assistive Technology Prior Approval Form indicating new equipment
and a comment about equipment returned
 Letter of developmental necessity indicating why original equipment was not
appropriate and how will new request better meet the needs of the child.
 Physician’s Script
 Picture and description of new item including manufacturer pricing, verification from
the vendor of return and funding status of the original item.
If vendor has not yet billed for the original equipment, process with submission of request to NCES.
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UF College of Medicine Department of Pediatrics North Central Early Steps
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CMS Early Steps Paying for Amplification for Children with Hearing Loss
Early Steps should not
pay for diagnostic
evaluations of children
referred following
universal newborn
hearing screening
(UNHS).
The Florida universal
newborn hearing
screening statute
(383.145, F.S.); requires
that “any necessary
follow up reevaluations
leading to diagnosis shall
be a covered benefit,
reimbursable under
Medicaid … all health
insurance policies and
health maintenance
organizations.” If a child
has no payer, then Early
Steps will reimburse for
this evaluation.
Some families may be
eligible for payment of
diagnostic hearing
services by the Sertoma
Speech and Hearing
Foundation of Florida.
http://www.familyheari
nghelp.org/Home.asp
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Children with hearing loss are eligible to receive Early Steps services and supports,
including amplification. These services are authorized via an Individualized Family
Support Plan, or IFSP. If Early Steps personnel are available, an interim IFSP can be
completed within a week or so of referral to Early Steps. An IFSP is required by law
to be completed within 45 days of referral. Amplification and hearing management
services as described below must be included on the IFSP and all funding sources
must be considered before Early Steps can pay. The audiologist will be considered a
member of the child’s IFSP team.
Procedures for prompt and consistent hearing aid use
1. Reporting: Audiologists are required to refer a child to the local Early Steps
Program within 2 working days of confirmation of a hearing loss that meets the Part
C eligibility requirements. The Diagnostic Hearing Evaluation Form has been
developed for audiologists to fax directly to the local Early Steps Program and to the
state CMS Newborn Screening Program. The audiologist can request that a free
hearing aid listening kit to be sent to them to provide to the family. The sooner that
Early Steps receives the referral the sooner amplification and other services can be
authorized as part of the IFSP service planning process.
2. Recommending Amplification: It is critical for amplification to be provided to a child
within one month of the recommendation being made by the audiologist. If for any
reason it appears that hearing aids will not be purchased within this 30 day period it is
important that the audiologist, family, and service coordinator work together to obtain
loaner hearing instruments through the Children’s Hearing Help Fund Hearing Aid Loan
Bank for Infants and Toddlers (http://www.childrenshearinghelpfund.com).
After the audiologist refers the child upon confirmation of hearing loss they can then
follow up by faxing a recommendation for amplification to the child’s Local Early
Steps office when sufficient evaluation has been performed to determine
amplification needs. For best results, when amplification is recommended the
audiologist should contact their Local Early Steps office and ask who the service
coordinator is for the child so the fax can be directed to this person. If the audiologist
is simultaneously making a referral to Early Steps and requesting reimbursement for
hearing aids then these two documents can be faxed to the service coordinator at
the same time. Authorization for reimbursement from Early Steps must be received
prior to fitting the hearing aids.
The IFSP team, including representation by the audiologist via their
recommendations, will discuss the amplification recommendation and whether to
provide authorization for purchase. When the referral and amplification
recommendation are simultaneous, there may be a delay in authorization of
amplification.
3. Billing Hearing Aid Fitting: When authorization from Early Steps is received, the
audiologist proceeds with the hearing aid fitting and then submits an invoice that
specifies one fitting fee ($115.00) per hearing aid. This fee covers (a) the earmold
impression appointment, (b) the hearing aid adjustment activities (c) the fitting and
hearing aid orientation appointment. The audiologist’s invoice also specifies the
manufacturer’s wholesale price of the hearing instruments (not to exceed $500 per
hearing aid or $1000 per pair). A copy of the manufacturer single unit price list or the
UF College of Medicine Department of Pediatrics North Central Early Steps
April 23, 2012
Special Hearing Aid Pricing for Florida Early Steps list with the selected hearing aid highlighted or circled must
also be submitted. The audiologist’s invoice specifies the cost of each earmold with a maximum reimbursement
rate of $18.00.
If the child’s insurance provides coverage for hearing aids then the insurance would pay a portion of the single
unit wholesale cost and Part C would pay the remainder (i.e., if insurance pays $300 then Part C would pay up to
an additional $200 per hearing aid). Balance billing is allowable only if the family is willing to pay for the excess
wholesale cost of a more expensive hearing aid. The audiologist would still need to submit evidence of the single
unit wholesale cost of the desired hearing aid. In addition, the audiologist would submit a written statement
signed by the responsible family member(s) showing that they have agreed to pay for the remainder hearing aid
cost. This balance billing arrangement is not allowable with Medicaid reimbursement of hearing aids.
4. Hearing Aid Follow Up Visits: It is recommended that the IFSP team specify hearing aid follow-up visits for all
children with amplification, including those who are Medicaid eligible. The suggested number of visits based on
the child’s age is offered below for use by IFSP teams when considering a child’s individual needs.
0-12 months of age - 12 visits (average 1 visit per month) maximum of $600
13-35 months of age - 6 visits (average 1 per 2 months) maximum of $300
Part C will reimburse hearing follow up visits, not to exceed reimbursement of $50 per event. It is anticipated that
each visit will take a minimum of 30 minutes. Ideally the hearing aid follow up visits would occur at a regularly
scheduled time to aid consistent attendance by the family (i.e., the first Thursday of each month at 10:00).
Hearing aid follow up visits will contain at least two of the following activities not otherwise reimbursable by
insurance:
a) Ear canal probe microphone measurements
b) Ear mold impressions
c) adjustment/programming of hearing instruments
d) Family training
e) Behavioral audiometric measurements not covered by another payer
f) Electro acoustic hearing aid analysis
g) Validation measures
h) in-office repairs of hearing instruments (not to include delivery after manufacturer
repair)
5. Hearing Aid Insurance: Loss and damage insurance ($65 per hearing aid per year) will be specified on the
Individualized Family Support Plans of all children with hearing aids that are out of warranty (including Medicaid
eligible). Following the IFSP meeting (typically the first annual evaluation of the IFSP) the appropriate Midwest
Hearing Industries hearing aid insurance pamphlet will be signed by the SHINE service coordinator. If the hearing
aid is still in warranty, the audiologist need not be involved. If the hearing aid is out of warranty it will be
necessary to request a written description of the condition of the hearing aids from the audiologist before the
application and payment from Early Steps can be sent in. Hearing aid insurance is an annual fee. When necessary,
the audiologist will submit a claim form and the wholesale price of the replacement hearing aid to the insurance
company. In the event that it is necessary to replace a hearing aid, Midwest Hearing Industries would reimburse
the audiologist for the cost of the hearing aid, up to $500 and the Local Early Steps would reimburse the
audiologist for two hearing aid follow up visits: one to make the ear mold and another to fit the new hearing aid.
If the hearing aid is accidentally damaged and needs repair, the audiologist would fax Midwest Hearing Industries
a claim form along with the repair invoice from the manufacturer, once the aid is repaired. Normal wear and tear
and general maintenance is not covered under the insurance. Part C is the payer of last resort for hearing aid
repairs.
6. Procedures for providing reimbursement for personal FM systems
An FM system is only effective when the caregiver consistently uses the microphone transmitter. If the family is
motivated to ensure that caregivers throughout the child’s day will wear the microphone transmitter, then a trial
period with this equipment should be considered. FM receivers can be added on to a child’s hearing aids or one
of the hearing aids can consist of a unit that is both a hearing aid and an FM system. The hearing aid loan bank
has several FMs that would be appropriate to use for trial periods. FM receivers are reimbursed only for one ear
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UF College of Medicine Department of Pediatrics North Central Early Steps
April 23, 2012
and the child’s hearing aid worn on the other ear, unless a combined hearing aid/FM receiver can be purchased at
$500 or less. At the end of the trial period it is recommended that the service coordinator obtain a copy of the
Early Listening Function (ELF) Infant and Young Child Amplification Use Checklist that has been completed by the
parents, typically with the assistance of the Hearing Specialist. If the trial period appears to have been successful
then it would be appropriate for the FM microphone transmitter and a unilateral FM receiver device to be
considered by the IFSP team for reimbursement by the Local Early Steps.
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Resources and Funding Sources
 The current Medicaid Provider Fee Schedules are to furnish the Medicaid provider with the appropriate fee
schedules for covered services provided to eligible Florida Medicaid recipients. The Medicaid Provider Fee
Schedules are provided in PDF, Microsoft Excel, and ASCII delimited format. The "Current Year" page includes fee
schedules that have been updated for 2011. Those fee schedules have their effective dates (01/01/11) in
parentheses next to their names.
http://portal.flmmis.com/FLPublic/Provider_ProviderSupport/Provider_ProviderSupport_FeeSchedules
/tabId/44/Default.aspx
 Florida Alliance for Assistive Service and Technology, Inc. (FAAST) is governed by the Assistive Technology Act of
2004. FAAST is sponsored by the Florida Department of Education, and is administrated through the Division of
Vocational Rehabilitation
http://www.faast.org/
 The Florida Diagnostic and Learning Resources System (FDLRS) provides diagnostic and instructional support
services to district Exceptional Student Education programs and families of students with exceptionalities
statewide. FDLRS includes twenty Associate Centers that serve from one to nine school districts. These Centers
collaborate with districts, agencies, communities and other personnel and educational entities, providing
education and support for teachers, parents, therapists, school administrators, and students with
exceptionalities. Each Center includes specialists in the areas of Child Find, Parent Services, Human Resource
Development (HRD), and Technology. FDLRS also includes five Statewide Centers that provide service and
support to the entire network. These include FDLRS/ATEN, FDLRS/FIMC, FDLRS/HRD, FDLRS/RMTC, and
FDLRS/TECH. In addition, five Regional Technology Centers provide technology support to the network and
districts.
http://www.fdlrs.org/docs/techContacts.pdf.
 Florida Children’s Medical Services www.cms-kids.com
 Florida Hearing Aid Loaner Program www.childrenshearinghelpfund.org
 Funding Assistance for Audiology Services www.asha.org/familyfunding
Please refer to Page 16 for more resources.
References
Individuals with Disabilities Education Improvement Act (IDEA) of 2004, PL 108-446,20 U.S.C. 1400 et seq.
Curry Sadao, K. & Robinson, N.B. (2010). Assistive Technology for Young Children: Creating Inclusive Learning
Environments. Baltimore, MA: Paul H. Brookes Publishing Company.
Department of Health, Children’s Medical Services, Early Steps (2010) Early Steps Policy Handbook and
Operations Guide.
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UF College of Medicine Department of Pediatrics North Central Early Steps
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Exhibit A: AT Activity-Based Provider Assessment Form
Child’s Name:
Provider Name(s):
DOB:
Service Coordinator:
Date:
Use this form to document steps taken for determining need for Assistive technology (AT) device.
If a child requires AT, submit this form along with NORTH CENTRAL EARLY STEPS ASSISTIVE TECHNOLOGY
REQUEST FORM
1st Step: What are child’s strengths, abilities, preferences and needs?
2nd Step: Identify routine activities for participation. What is preventing the child from participating more?
3rd Step: Brainstorm AT solution: List what is presently available and adaptable (consider a full range of options,
from low-to-high tech, and strategies to support use) and where and when is device to be used?
Provider Signature(s):
Date:
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UF College of Medicine Department of Pediatrics North Central Early Steps
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Appendix B: North Central Early Steps Assistive Technology Request Form
NORTH CENTRAL EARLY STEPS ASSISTIVE TECHNOLOGY REQUEST FORM
North Central Early Steps
1329 SW 16th Street, Room 4160
Gainesville, FL. 32608
Ap
Tel:352/273-8555
or 1-800-334-1447
Fax: 352/273-8588
Date of Submission:
Requested By:
Comments:
Please print clearly, complete entire request form and include required attachments.
Child’s Name:
DOB:
Medicaid Eligible? (Circle one) NO
If YES, enter 9-digit Medicaid # here: ____ ____ ____ ____ ____ ____ ____ ____ ____
If TPIN (Please Attach Insurance Denial):
Loaner or natural supports were provided and used by the family/caregiver, if available?
Yes
No
Comments:
IFSP Team members:
Item(s) Recommended: (Please attach: Copy of Catalog Description and Price)
Item
Model
Manufacturer
Vendor
Medicaid DME Code
Price at Medicaid
Rate
The Following Documentation must be included with this request:
_______ AT Activity-Based Provider(s) Assessment Form
_______ IFSP sections: Page E, F and G
_______Copy of Dated & Signed credentialed evaluator letter of necessity supporting request
_______ Copy of Dated & Signed Physician’s Prescription
_______ Copy of vendor quote including options/accessories breakdown
_______ Picture & pricing of item(s)
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UF College of Medicine Department of Pediatrics North Central Early Steps
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Appendix C: AT Device Request Form
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UF College of Medicine Department of Pediatrics North Central Early Steps
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Appendix D: AT Device Receipt Form
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UF College of Medicine Department of Pediatrics North Central Early Steps
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