Form 6507, Rationale for Adaptive Aids, Medical Supplies, and Minor Home Modifications

Instructions

Updated: 4/2004

Purpose

To serve as the primary documentation for all adaptive aids, medical supplies, and minor home modifications requested in the Deaf Blind with Multiple Disabilities (DBMD) Program.

Note: Completion of this form does not guarantee that the requested item(s) will be approved.

Procedure

When to Prepare

This form, or an alternate form of documentation, is prepared any time an adaptive aid, medical supply, or minor home modification has been identified as a need for an individual, such as on the pre-enrollment home health visit, the annual reassessment, or any time there is a request for a service plan change. The adaptive aid, medical supply, or minor home modification should be listed in the Individual Program Plan, as appropriate.

A physician (MD/DO), registered nurse (RN), speech pathologist (SP), occupational therapist (OT), physical therapist (PT), physician assistant (PA), or nurse practitioner (NP) completes this form for every adaptive aid, medical supply, or minor home modification requested and included in the Individual Service Plan (ISP), whether it is listed in the Deaf Blind with Multiple Disabilities Handbook or not.

The HCSS agency is responsible for completing, or assuring the completion of, this form or the alternate documentation.

Number of Copies

Complete an original and two copies of Form 6507 for each item requested for purchase as a DBMD adaptive aid, medical supply, or minor home modification. Two items can be requested per page.

Transmittal

When the requested item is already listed in the handbook as an approved adaptive aid, medical supply, or minor home modification, the provider agency retains the original.

One copy is given to the case manager and one copy is given to the participant requesting the adaptive aid, medical supply, or minor home modification.

When the requested item is not listed in the handbook as an approved adaptive aid, medical supply, or minor home modification, the provider agency retains the original. The provider agency submits this form with the Individual Service Plan to the DBMD contract manager. An additional copy is made and given to the participant requesting the adaptive aid, medical supply, or minor home modification.

Form Retention

Retain this form according to the terms and conditions in the DBMD Handbook.

Detailed Instructions

Applicant/Individual's Name — The provider agency staff enter the name of the applicant/participant.

Provider Vendor No. — Enter the DBMD vendor number.

Medicaid Number — Enter the applicant's Medicaid number, or Social Security number if a Medicaid number is not available. For a individual, enter his Medicaid number.

Age — Enter the age of the applicant/individual.

Specify the Individual's Diagnosis/Medical Condition and Functional Limitations — Enter specific information regarding the listed items.

Item 1 and Item 2 Instructions

A. Specify the medical supply, adaptive aid, or minor home modification — Enter the individual item, or group of related items, being requested, including details, specification, or brand names as necessary to describe the request.

B. Describe why the item is necessary and how the item benefits the individual in terms of treatment, rehabilitation, or ability to compensate for functional limitations — The physician (MD/DO), registered nurse (RN), speech pathologist (SP), occupational therapist (OT), physical therapist (PT), physician assistant (PA), or nurse practitioner (NP) documents why the requested adaptive aid, medical supply, or minor home modification is necessary and specifically how it will benefit the individual medically, functionally, or in terms of rehabilitation.

Signature of Professional — The MD/DO, RN, PT, OT, SP, PA, or NP signs the form.

Date — The MD/DO, RN, PT, OT, SP, PA, or NP enters the date.

Printed Name of Professional — The professional completing the form prints or types his name.

Title — The professional completing the form prints or types his title.

Telephone No. — The professional completing the form enters his telephone number.