Healthcare AT Report

Healthcare AT Report

Patient Information

Date of Birth:   Gender:   Patient ID/Medical Record #:

Phone:   Email:

Relationship:   Phone:

Insurance & Funding

Policy/ID #:   Group #:   Subscriber Name:

Referral & Assessment Details

Referring Provider:   Referral Date:

Assessment Date:   Location of Assessment:

Relevant Medical & Functional History

Functional Assessment

Goals & Desired Outcomes

Recommended Assistive Technology

Risks, Limitations & Maintenance

Funding & Cost Estimates

Payer Approval Required:   Patient Agrees to Pursue Funding:

Clinician Findings & Certification

I hereby certify that, to the best of my professional knowledge, the foregoing assessment and recommendation are accurate and appropriate for the identified patient based on clinical evaluation, trial data where applicable, and current practice standards. Clinician will document objective measures and supporting clinical rationale provided to payer as required.

Patient Authorization & HIPAA Acknowledgment

By signing below I acknowledge that I have received and understand this Healthcare AT Report, including the recommended assistive technology, associated risks, and maintenance responsibilities. I authorize release of relevant clinical information to payers, suppliers, and other providers as necessary for procurement, funding, or delivery of the recommended device. This authorization is voluntary and may be revoked in writing; revocation will not affect actions taken prior to receipt of revocation.

Authorization Expiration Date:

Patient / Authorized Representative acknowledges receipt of the facility's privacy practices and consents to the use and disclosure of protected health information as described above.

Acknowledgment:   I acknowledge and consent to the statements above.

Additional Notes / Follow-up Plan

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