Medicare Checklist for SGD Equipment Speech Generating Devices (Communicator 25, 35, 600 and 3500)

A.  Speech/Language Evaluation
(Click here to download a Sample Speech/Language Evaluation)
__ Client's name
__ Date of birth
__ Medical diagnosis
__ Date of onset
__ Specify place of residence

1. Home
2. Skilled Nursing Facility
3. Nursing Facility
4. Custodial Facility (assisted living)
5. Intermediate Care Facility/Mentally Retarded Facility

__ Current communication impairment

1. Indicate type of communication impairment
2. Describe impairment severity
3. Explicitly demonstrate how the medical condition results in severe expressive speech

__ Anticipated course of impairment

1. Demonstrate the current status and expected course of speech as it relates to the condition

__ Language skills

1. Describe level of linguistic impairment as it relates to the person's ability to use a SGD (Speech Generating Device) and accessories

__ Cognitive ability

1. Provide information about the person's cognitive skills and abilities as they relate to the use of the SGD and accessories
2. Report should state, "The patient possesses the cognitive/linguistic abilities to effectively use a SGD to communicate and achieve functional communication goals

__ Vision Status
__ Hearing Status
__ Physical Status
__ Daily Communication Needs

1. Specify daily functional communication needs
2. Ability to fulfill these needs using natural speech, electronic aids and other non-SGD treatment approaches

__ Functional communication goals

1. List immediate, short terms and long term functional communication goals
2. Goals should correspond to specific daily functional communication needs and illustrate how the patient's speech disability will benefit from acquisition and training of on the SGD

__ Rational for device selection

1. Explain why certain device features are required
2. Provide data that leads to the selection of a specific device and accessories
3. Characteristics features
4. Output features
5. If accessories are recommended (eg. wheelchair mount), explain medical need in detail

__ Description of equipment and procedures used to show recommended SGD. (Eg. Product documentation, evaluation software)
*Note:  Hands-on equipment demonstration is not required* 
__ SGD and accessories recommended (eg. Communicator 3500,
     extra battery)
__ Patient/family support of SGD
__ Physician involvement statement

1. The report should say, "This report was forwarded to the treating physician (name, license #) on (date). Plus note on the evaluation with CC.
   - OR -
2. Must have original physician signature on the evaluation

__ Treatment plan (eg. SGD training for client/family)
__ SLP assurance of financial independence 
     (SLP may not be an employee or have a financial relationship 
       with the supplier of the SGD)
__ Signature of licensed SLP (must be original and must have CCC)

B.  Prescription/Certificate of Medically Necessity 
       Download Certificate of Medical Necessity (MS Word format)
__ Prescription from physician (must be an original signature)
__ Physician's UPIN number
__ Client's name
__ Client's diagnosis
__ List of equipment that is being prescribed.  Must be specific.
      (eg. Communicator 3500, Extra battery, wheelchair mount, switch).

C.  Complete/Sign "Form HCFA1500" 
__To order/obtain Form HCFA1500, Click here to order form
     ** Note:  Do not complete secondary insurance coverage section (see below) 

D.  Send A, B, and C to...
         Gus Communications, Inc.
         1006 Lone Tree Court 
         Bellingham, WA 98226

** You must include 20% of the total cost of the order along with your documentation.  If you have Medicaid or other insurance company which may cover this 20%, you must submit a claim directly to them after receiving your SGD.  We cannot process secondary insurance claims for the 20% not covered by Medicare.  

If we have any questions or require additional information we will contact you.

Assuming the documentation is complete, your SGD equipment will arrive in approximately 2 weeks.

If you have any questions, please call .... 360-715-8580

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