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PATIENT NAME:
ADDRESS:
TELEPHONE:
MEDICARE ID NUMBER:
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SUPPLIER
Augmentative Communication Consultants, Inc.
P. O. Box 731
Moon Township, PA 15108
OFFICE 412 264-6121 begin_of_the_skype_highlighting 412 264-6121 end_of_the_skype_highlighting FAX 412 269-0923
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| PLACE OF SERVICE
NAME of FACILITY if applicable
Address of FACILITY
CITY STATE
ZIP
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HCPCS
CODE
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PATIENT DOB FEMALE MALE
PHYSICIAN NAME:
ADDRESS:
CITY: STATE:
ZIP: PHONE: NPI:
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| 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 |
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ITEM
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ANSWERS
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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.
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SGD and All Accessories
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Y N D
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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?
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Y N D |
2. Does the patient have a medical condition resulting in a severe expressive speech disability? |
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Y N D |
3. Can the patient's speaking needs be met using natural communication methods? |
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Y N D |
4. Have other forms of treatment been considered and ruled out? |
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Y N D |
5. Will the patient's speech disability benefit from the device? |
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Accessories
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Y N D |
6. Has the medical necessity for each accessory been documented in the formal evaluation? |
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Repairs
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Y N D |
7. Does the patient have continued medical need for the device/accessory for which the repairs are requested? |
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Upgrade/Replacement
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Y N D |
8. Does the upgrade/replacement provide enhanced features or other improvements? |
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NAME OF PERSON ANSWERING SECTION B QUESTIONS, IF OTHER THAN PHYSICIAN: NAME:
TITLE: EMPLOYER:
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| SECTION C Narrative Description of Equipment and Cost |
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(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)
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| SECTION D Physician Attestation and Signature/Date
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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
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