Instructions for the Essential Information Form General In order to obtain an Assistive Technology device/service, specific information is required when Medicare, Medicaid, and other medical insurance, is being accessed for reimbursement. Your ability to provide complete and accurate information will insure that the process is not interrupted due to missing information. You will be asked to provide the information about insurance several times over the course of obtaining the assistive technology equipment. This form was designed to allow you to collect the information once and respond to the several requests that will be made by service providers, vendors, and payers over the course of obtaining the AT device/service. Please complete each and every blank on this form, as every piece of information is important! Section I: Please complete this information as it relates to the consumer who is being referred for an AT device/service. Section II: This information identifies a contact person who could answer questions or has access to information about the individual consumer. This section identifies who can act on behalf of the consumer needing the service. Section III: This section requests information about the medical insurance coverage. In many cases an individual may be covered under more than one, or even two, plans. Please provide all information about Medicare, private insurance, and Medicaid in this section even when a plan may not cover AT devices/services. If an individual has more than 2 types of coverage please attach additional insurance information. Please be sure to identify who the policyholder is (the name of the individual in whose name the policy is issued, their social security number etc). Attach a copy of BOTH sides of each insurance card. Section IV: This section requests information about the consumer's primary care physician. Each physician has a Unique Physician Identification Number (UPIN), a State License number, and many will have a Medicaid Provider number. Very often these numbers are listed on the physician's prescription form. If they are not listed on the prescription form, obtain them from the physician’s office. Section V: You can not procure an AT device/service without a prescription. Depending on the payer’s requirements, you may need to obtain multiple prescriptions to cover the evaluation, the device, and/or other services. Essential Information Referral Form for AT Medicare/Medicaid Purchase & Repairs I. Name __________________________ Height_______ Weight____________ Address ___________________-_____________________________________ Phone # ____________ DOB_____ Social Security # _____________________ II. Contact Person's Name ___________________________________________ Relationship to Consumer: ___________________________________________ Address _________________________________________________________ Phone: Home _____________ Phone: Work __________ Fax _____________________ Email address____________________________________________________ III. Primary Insurance _______________________________________________ Policyholder Name ________________________________________________ Policyholder Address _______________________________________________ Policyholder Phone _______________ Policyholder Date of Birth ____________ Policyholder Social Security # ________________________________________ Policyholder Relationship to Consumer_________________________________ Secondary Insurance _______________________________________________ Policyholder Name _________________________________________________ Policyholder Address _______________________________________________ Policyholder Phone ________________ Policyholder Date of Birth ___________ Policyholder Social Security # ________________________________________ Policyholder Relationship to Consumer_________________________________ Copy of Card (Attach copies of card. Copies of all insurance cards will be required) IV. Referring Physician _________________________ UPIN # ______________ State License # ___________________________________________________ Referring Physician Address _________________________________________ Referring Physician Phone Number____________________________________ Medicaid Provider # ________________________________________________ V. Original (not fax) Prescription (specific to request) Patient Name_____________________________________________________ Diagnosis (specific to what you are requesting) __________________________ Service Requested ________________________________________________ Date of Onset _____________________ Prognosis _______________________ Length of Need __________________________________________________ Equipment Needed (list each item - device, mount, switch, etc.) _____________________________________________________________________________ What other equipment is being used in the home by this individual? ________________________________________________________________ Who provided it? _________________________________________________ Person Completing Form ______________________ Date _________________ Relationship to consumer____________________________________________ Address _________________________________________________________ Phone Number__________________________ Fax_______________________ Email address ____________________________________________________