DATE
RE: (NAME)
D.O.B.
ID #
Dear Ms/Mr.(CASE MANAGER) :
I am writing to request authorization
for payment for an augmentative/alternative electronic communication system
(AAC) for (NAME). (NAME) has (DIAGNOSIS) and (ALTERNATE DIAGNOSIS – Multiple), both/all
of which have severe delays with (his/her) expressive language. (NAME) completed (__) years of schooling in
the public school system. (His/Her)
inability to communicate affected (his/her) ability to reach (his/her) true
potential. (A few individual specific
sentences about the current educational and speech support he/she is receiving). Both at school and in private speech therapy (NAME)
is using a simple iPad with the (Proloquo2go http://www.proloquo2go.com/) which is an
AAC program and is installed by the manufacturer. I understand many public schools also use the
same device and program, and is quickly becoming the industry standard. The program is user friendly and (NAME) is
doing very well in trials at school and therapy. It is quickly replacing the larger, bulkier
communication boards among professionals.
Not only will using such a device and program benefit (him/her) speech
wise, it will also have wonderful fine motor skill development benefits.
SAMPLE OF SPECIFIC SUPPORTING DETAILS:
_______________________________________
(NAME) has good receptive language and
is able to follow simple instructions.
As (he/she) continues to become more independent it is becoming
frustrating for (him/her) to not be able to express himself. This will eventually affect (his/her) social
development thus creating a whole new set of concerns. This device is medically necessary in order
for (NAME) to be able to indicate (his/her) physical and health status (such as
giving details about feelings when ill or in pain), letting others know of (his/her)
personal needs and wants, and to request help (especially in emergency
situations when (NAME) is at school or with caregivers who may not be familiar
with (NAME)’s poor and limited speech).
________________________________________
The iPad with the Proloquo2go program
should definitely qualify as medical equipment as it is a speech generating
device which is directly related to (NAME)’s diagnosis and current therapy
program; replaces the abnormal functioning of a body function (verbal speech);
is expected to be used for a long-term and will grow with (him/her); and, it is
appropriate to improve (NAME)’s current and future language to assist in
activities of daily living both at home and at school. It would certainly be more cost effective and
age appropriate than the more complicated Dynavox systems currently available.
Thank you for your assistance in making
this device available to (NAME) and his family and helping to improve (his/her)
health care and functional abilities and independence. Please call me at (PHONE)
if I can provide any additional information.
Sincerely,
NAME, DESIGNATION
OFFICE CONTACT INFO