Essential Information Form
Instructions
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 _____________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 ____________________________________________________