Form Ddd-1151a - Augmentative Alternative Communication (Aac) Referral Packet
Download a blank fillable Form Ddd-1151a - Augmentative Alternative Communication (Aac) Referral Packet in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Ddd-1151a - Augmentative Alternative Communication (Aac) Referral Packet with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5
6
7
8
9ARIZONA DEPARTMENT OF ECONOMIC SECURITY
DDD-1151A FORFF (1-18)
Page 1 of 9
Division of Developmental Disabilities
INSTRUCTIONS FOR COMPLETION OF THE AUGMENTATIVE ALTERNATIVE COMMUNICATION
REFERRAL PACKET BY A CERTIFIED SPEECH-LANGUAGE PATHOLOGIST
PRIOR TO COMPLETION OF THE AAC REFERRAL PACKET, THE SLP MUST INFORM THE SUPPORT COORDINATOR
THAT AN AAC EVALUATION HAS BEEN DETERMINED MEDICALLY NECESSARY FOR THE MEMBER
AAC Referral Packet Contents:
1) Demographic Information.
2) ISP Information: Attach a copy of the most current ISP. If you do not have this information, you will need to request
the ISP from the Support Coordinator. The ISP must be submitted with the Packet. If the member does not have an
ISP and they are under the age of 3, an IFSP must be submitted.
3) Insurance Information: Include a legible copy of any third party payor card, both front and back (this is the member’s
private insurance). This includes Medicare. If you do not have this information, you will need to request this from
the Support Coordinator. A copy of the insurance card must be submitted with the Packet. The AHCCCS card is not
required upon submission.
4) Evaluator Choice: The Speech Language Pathologist will ask the member which provider they would like to have
perform the evaluation and training. THIS MUST BE FAMILY CHOICE. In addition, remind the family that the team
completing the evaluation will be responsible for the training as well.
5) Communication Skills Questionnaire (CSQ): Must be completed by a Speech-Language Pathologist holding their
Certificate of Clinical Competence (CCC). If you are a CF or SLP-A, the CSQ must be cosigned by your supervising
Speech-Language Pathologist. Add as much description as possible to assist the evaluators in providing a thorough
evaluation. IF your recommendation is that the member would benefit from a communication device, you must
explain why in detail.
6) The SLP will give the completed packet back to the family so that they may obtain the signature and office
notes from the face-to-face visit with their physician.
7) The family will submit the signed Packet to the SLP or Support Coordinator for submission. The SLP or Support
Coordinator may submit the Packet via email to the AAC inbox.
ADDITIONAL INFORMATION FOR SCHOOL SYSTEMS:
1) CSQs completed by school SLPs: Complete the CSQ in its entirety and submit to DDDAugComms@azdes.gov.
The Augmentative Alternative Communication Unit will obtain the remaining information (ISP, insurance, etc.).
The Support Coordinator is responsible for giving the packet back to the family to obtain a signature from
their physician.
2) If the school is completing the AAC evaluation, this Packet does not need to be completed. The school system
should send the evaluation, including quote page, to DDDAugComms@azdes.gov.
*PACKET MUST BE COMPLETED IN ITS ENTIRETY OR THE PROCESS WILL BE DELAYED*
Send completed packet to DDDAugComms@azdes.gov.
For mail options, contact the AAC Department for further instructions via the above email address.
Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the
Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of
1975, and Title II of the Genetic Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination in
admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age, disability,
genetics and retaliation. To request this document in alternative format or for further information about this policy, contact
the Division of Developmental Disabilities ADA Coordinator at 602-542-0419; TTY/TDD Services: 7-1-1. • Free
language assistance for DES services is available upon request.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal