|
PATIENT NAME:
ADDRESS:
TELEPHONE:
MEDICARE ID NUMBER:
|
SUPPLIER
Augmentative Communication Consultants,
Inc.
P. O. Box 731
Moon Township, PA 15108
OFFICE 412 264-6121
FAX 412 269-0923 |
| PLACE OF
SERVICE
NAME of FACILITY if applicable
Address of FACILITY
CITY
STATE
ZIP
|
HCPCS
CODE
|
PATIENT
DOB
FEMALE
MALE
PHYSICIAN NAME:
ADDRESS:
CITY:
STATE:
ZIP:
PHONE:
UPIN: |
|
SECTION B
Information in This Section May Not Be Completed by the Supplier of
the Items/Supplies. |
|
EST. LENGTH OF NEED ( # OF MONTHS)
1-99 99=LIFETIME |
DIAGNOSIS
CODES ICD-9 |
|
ITEM |
ANSWERS |
ANSWER QUESTIONS 1-6 FOR SGD.
OPTION/ACCESSORIES
7 FOR REPAIRS, 8 FOR
UPGRADE/REPLACEMENT.
(Y FOR YES, N FOR NO, D FOR DOES NOT
APPLY) unless otherwise noted. |
|
SGD and
All Accessories
|
Y
N
D
|
1. Has the patient had a formal
evaluation of cognitive and language ability by a SLP with no
financial connection to supplier and a copy of the evaluation
submitted to the treating physician? |
|
|
Y
N
D
|
2.
Does the patient have a medical condition resulting in a severe
expressive speech disability? |
|
|
Y
N
D
|
3.
Can the patient's speaking needs be met using natural communication
methods? |
|
|
Y
N
D
|
4.
Have other forms of treatment been considered and ruled out? |
|
|
Y
N
D
|
5.
Will the patient's speech disability benefit from the device? |
|
Accessories |
Y
N
D
|
6.
Has the medical necessity for each accessory been documented in the
formal evaluation? |
|
Repairs |
Y
N
D
|
7.
Does the patient have continued medical need for the
device/accessory for which the repairs are requested? |
|
Upgrade/Replacement |
Y
N
D
|
8.
Does the upgrade/replacement provide enhanced features or other
improvements? |
|
NAME OF PERSON ANSWERING SECTION B
QUESTIONS, IF OTHER THAN PHYSICIAN: NAME:
TITLE:
EMPLOYER:
|
|
SECTION C
Narrative Description of Equipment and Cost |
|
(1) Narrative description of all
items, accessories and options ordered; (2) Supplier's charge;
and (3) Medicare Fee Schedule Allowance for each item, accessory,
and option. (See instructions)
|
|
SECTION D
Physician Attestation and Signature/Date |
|
I certify that I am treating physician
identified in Section A of this form. I have received Sections
A, B and C of the Certificate of Medical Necessity, (including
charges for items ordered). Any statement on my letterhead
attached hereto, has been reviewed and signed by me. I certify
that the medical necessity information in Section B is true,
accurate and complete, to the best of my knowledge, and I understand
that any falsification, omission, or concealment of material fact in
that section may subject me to civil or criminal liability. SIGNATURE AND DATE
STAMPS ARE NOT ACCEPTABLE
PHYSICIAN'S SIGNATURE
DATE
|