For Standing Devices - Amazon Web Services...Two funding resources we feel are particularly helpful...

FUNDING GUIDEFor Standing Devices

Table of Contents

Purchasing*. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Team Process . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Letter of Medical Necessity*. . . . . . . . . . . . . . . . .

Research & Articles . . . . . . . . . . . . . . . . . . . . . . .

Appeals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Legal & Resource Services . . . . . . . . . . . . . . . . . .

Coding*. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Evaluation Worksheets*. . . . . . . . . . . . . . . . . . . .

Benefits of Standing Poster*. . . . . . . . . . . . . . . .

EasyStand Product Poster . . . . . . . . . . . . . . . . .

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*Excerpt from NCART Standing Device Funding Guide (May 2013)

Standing devices are considered Durable Medical Equipment (DME) and are categorized as Complex Rehab Technology (CRT). These devices must be individually assessed and configured for best outcomes. They are designed to support a consumer, regardless of age, in a standing position.

If a Complex Rehab Technology (CRT) Supplier will not call you back, or tells you standing devices are never covered, contact us at Altimate Medical 800.342.8968 for assistance.

Step 1: Therapist and/or Physician determine medical necessity for a standing program Before initiating a standing program, medical clearance is critical for the consumer to stand. Clinical data, and a review of relative risks and benefits of use, determine medical necessity. This information is gathered through clinical assessment and should, at minimum, include the following: •Consumerdata •Physicalfindings •Measurements

Step 2: Rehab Team determines the most appropriate standing device for the Consumer Using the assessment data and goals for the consumer, consider all standing device options and select the device that is the least costly, equally effective alternative.•TherapistandConsumerscheduleanappointmenttotrialtheselectedtypeofstandingdevice.Involvea complex rehab technology supplier (and possibly manufacturer’s representative) to ensure appropriate set up of the trial equipment. •Based on the results of the trial, determine the specific model of standing device required and necessary support and alignment options. •Ensure the consumer/caregiver is able to successfully utilize the device and its features and will work in all intended environments.

Step 3: Gather necessary documentation from the Rehab Team for product justification Requests for authorization of standing devices are typically submitted by the CRT supplier and must be accompanied by clinical documentation from a licensed physician or occupational or physical therapist. The writer should establish their expert credentials by describing: expertise, licenses, education, current job title and years of experience at the beginning of the Letter of Medical Necessity (LMN). Documentation must support the medical necessity for this equipment. You can find examples of LMNs on our website under the tab “Funding Guide.”

Step 4: Payment decision is received from funding source•Approval:Paymentapprovalisgranted-thesupplierwillordertheequipmentandscheduledeliverywith the consumer and prescribing clinician. •Denial:Iffacedwithadeniedclaim,alwaysappealthedecision(seeappealssection).

easystand.com/funding

Purchasing

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Team Process

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For the greatest success getting Complex Rehab Equipment (CRT) paid for by a funding source, utilize the “Team Process.” While those involved vary case to case, the team is often comprised of the DME/CRT supplier, clinician(s), the consumer and often a caregiver or family member.

Consumer’s Role: •Astheleader,theyneedtofollowtheprogressionofthefundingprocessthroughitsconclusion •Chooseacomplexrehabtechnologysupplierthatiswillingtoworkwithyouandyourpayer(s) •Beawareofthemedicalneedtostand •Researchthebenefitsofstanding •Specifywantsandneedsforstandingdevice •Trialanddeterminethestandingdevice •Bepresentforthefinaladjustment •Appealifnecessary(theconsumerorlegalguardianmuststarttheprocess) •Followthroughwithstandingprogram(oncedeviceisreceived/adjusted)toachieveexpectedoutcome

Caregiver/Family’s Role: •Assumetheroleoftheconsumer(ifconsumerisaminororunabletoperformthetask) •Providesupportandfeedbacktotheteamontransfertechniques/activitiesofdailyliving,etc.

Rehab Technology Supplier’s Role: •Providetrialstandingdeviceorscheduleproducttrialwithalocalmanufacturer’srep •Offerexpertiseonstandingdeviceandavailableoptions •Acquirepriorauthorizationwiththefundingsource •Assemble,deliverandadjustdeviceforproperfit •Assistwiththeappealsprocessasnecessary

Clinician’s Role: •Determinemedicalclearancefortheconsumertostand •Clinicianrecommendsweightbearing/standingdeviceandprogram •Clinicianreviewsstandingdeviceoptionsandmakesrecommendations •Clinicianwritestheletterofmedicalnecessity(LMN)includingtrialprocess •Physicianusuallyco-signsthetherapist’sLMNorwritesanadditionalprescription •Clinicianusuallyattendsandassistsinthefinaladjustmentofthestandingdevice • If the standing device is denied, clinician writes addendum or new LMN and/or attends appeals hearing •Clinicianshouldmonitortheclient’songoingstandingprogram

1. A detailed letter of medical necessity (LMN) contains: •Writer’sexpertcredentials •Consumer’sname,dateofbirth,weightandheight •Historyandphysicalexambyclinicianincludingsummaryofmedicalcondition,diagnosis/onset, prognosis, and co-morbid conditions •Functionalandphysicalassessmentincluding,butnotlimitedto,strength,rangeofmotion,tone, sensation, balance, ADLs, IADLs, and functional status •Documentationofotherdevicesconsidered,andwhyeachwasineffectivefortheconsumer •Documentationoftrialeddevice(s)andoutcomesofthetrial(s) •Justificationofthemodelofdevicebeingrecommendedaswellaseachoptionandaccessory required for the consumer •Evidencethattheconsumerdemonstratedtheabilitytosafelyusethedeviceindependentlyor with appropriate assistance •Outlineoftheprescribedstandingprogramrecommendations •Anyapplicableresearchtosupportintendedoutcomes

2. A prescription for the device from the consumer’s physician (this is typically a co-signature on the LMN stating the physician agrees with the prescribed device). All appropriate medical professionals involved in the consumer’s care, as it relates to standing should also co-sign the LMN or provide additional documentation to support need. Examples include: Physiatry (Rehabilitation Medicine), Neurology, Orthopedics,Cardiology,Urology,PrimaryCare,OccupationalTherapy,PhysicalTherapy,Speech Language Pathology, Psychology, etc.

3. Documentation that the consumer’s environment can accommodate the device

4. Detailed quote and/or order form for items being requested

5. Any other information required by the specific funding source


A letter of medical necessity (LMN) is a detailed prescription a clinician writes and is submitted to the funding source. Visit our website for specific examples of LMN’s, as well as articles and resources that help create an effective letter. The letter should be consumer specific, not just a list of the medical benefits of standing.

Documentation must communicate the process that was followed, the options that were considered, and the medical necessity for the requested equipment. The documentation should include all of the following (use information obtained from the Standing Device Evaluation Worksheet to help create this documentation):

Letter of Medical Necessity

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Research Studies Support Standing Physicians and therapists have recommended standing/weight bearing for people with a range of disabilities and based on a variety of medical benefits. Passive standing has been demonstrated to prevent, reverse, or improve many of the adverse effects of prolonged immobilization. We have compiled over 200 research studies and articles documenting the many benefits of standing. Visit our website and search by health benefit, diagnosis, author or title. We provide links to the abstract or full article when available.

easystand.com/health-benefits

Medical Benefits of Standing Literature •PreventCalciuriaandMaintainorGainBoneDensity •ReduceSpasticity,Tone,Spasms •MaintainRangeofMotion,PreventContractures •ImproveCirculation/Respiratory/CardioFunction •DeveloporImproveMotorFunction •PromotePsychosocialSkillsandImproveSleep •ImproveBladderFunction •ImproveHipIntegrity •ManagePressureUlcers/MaintainSkinIntegrity •ImproveBowelFunction&Digestion •ImproveStrength •ImprovePainManagement •StandingProtocolandBenefitsofStandingOverview •EffectsofImmobilization •ReviewofLiterature Activity Specific Studies •Active(ReciprocalLegMovement)Standing •WeightBearing&FunctionalElectricalStimulation(FES) •Mobile/DynamicStanding •VibrationWhileStanding Diagnosis Specific Studies •SpinalCordInjury •CerebralPalsy •Stroke •MultipleSclerosis •MuscularDystrophy

Other •School-BasedTherapy •Elderly/Long-termCare/NursingHomes •Funding/DocumentationforStandingDevices •StandingDeviceComparison/ProductEvaluation

Research & Articles

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Step 1: Don’t take “No” for an answer Appeal if denied! The consumer must start the appeals process.

Step 2: Review the submitted documentation Was it complete? Does it include the devices considered, the equipment trial process and the individual’s specific medical needs? If you are not comfortable reviewing the letter of medical necessity fax it to 952-937-0821or email [email protected] and we will be happy to assist with the review.

Step 3: Request an appeal in writing This written request must be received by the funding source within a specified time frame, usually within 90 days. Send a copy of the notice of denial with the funding appeal letter and keep the originals. The notice includes necessary information such as recipient’s name, address, and ID number.

Step 4: Referee will be assigned to hear the appeal The referee may schedule a telephone hearing. Although, you have the right to an in-person hearing which is usually preferable. You can, in fact, state in the letter that the hearing be held in-person.

Step 5: Identify potential expert witnesses SuchasaPhysicalTherapist,OccupationalTherapistorPhysiatrist.In-persontestimonyisdesirable; however, it is acceptable to have testimony by phone or in a written letter of medical necessity.

Step 6: Assistance from an advocate or attorney PAAT (Protection Advocacy for Assistive Technology) attorneys are a free resource available to assist clients with disabilities and their families as they seek funding for Assistive Technology. Visit the “funding guide” tab on our website for a directory of legal and funding services.


While the benefits of standing are numerous, occasionally, funding sources do not agree with consumer needs. Many standing devices have been paid for after an appeal. EasyStand is here to help you understand and navigate the appeals process for standing devices. Visit our website for resources to appeal an equipment denial.

Appeals

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Two funding resources we feel are particularly helpful for standing devices and other complex rehab technology are the Protection Advocacy for Assistive Technology (PAAT) attorneys and the Assistive Technology (AT) Project in each state. Visit the “funding guide” tab on our website for a directory of funding and legal services.

PAAT Attorneys PAAT attorneys and advocates are a free resource available to assist people with disabilities and their families as they seek funding for AT. PAAT locations throughout the U.S. offer support, resources and guidance through the appeals process.

AT Projects Each state has an AT Project that has information about assistive technology resources for that state. The goal of AT Projects is to increase access to assistive technology for all people. Services that may be provided include:•AwarenessactivitiesaboutATanditsuses•AdvocacyforindividualsandtheirfamiliesaboutrightstoATservices•TechnicalassistanceselectingtheappropriateATdevices•ShorttermloanofATequipmenttotryoutatwork,home,school,etc.•ATresourceinformationandreferraltootherprograms


Legal & Resource Services

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Coding

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Evaluation WorksheetsNCARTStandingDeviceEvaluationWorksheet

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DevelopedbytheNCARTStandingDeviceWorkgroup(May2013)IntroductionThisEvaluationWorksheetprovidesclinicians,suppliersandconsumerswithanoutlineoftheevaluationprocesstodeterminemedicaljustificationforastandingdeviceandtodeterminethemostappropriateoptiontomeetanindividual’sneeds.CliniciansandsuppliersareencouragedtoreviewrelatedinformationcontainedintheNCARTStandingDeviceFundingGuide.Standingdevicescanbeastandalonepieceofequipmentormaybeincorporatedintoamanualorpowerwheelchairbase.Thisevaluationworksheetcanbeusedwhenconsideringtheprescriptionofanytypeofstandingdevice,butitdoesNOTreplacetheletterofmedicalnecessity(LMN).TheinformationinthisevaluationworksheetwillhelpthecliniciancollectdatathatcanthenbeusedtowritethedetailedLMNfortheconsumer.Remember,thisevaluationworksheetdoesNOTreplacetheletterofmedicalnecessity.Allappropriatemedicalprofessionalsinvolvedintheconsumer’scareasitrelatestostandingshouldsigntheLMN.Examplesinclude:Physiatry(RehabilitationMedicine),Neurology,Orthopedics,Cardiology,Urology,PrimaryCare,OccupationalTherapy,PhysicalTherapy,SpeechLanguagePathology,Psychology,etc.I.ConsumerDataConsumerInformationName: ________________________________________________________________________________________Address:______________________________________________________________________________________ City,State,Zip:______________________________________________________________________________Homephone: ________________________________________________________________________________Workphone:_________________________________________________________________________________Socialsecurity#:____________________________________________________________________________Dateofbirth:_________________________________________________________________________________Parent/GuardianName: ________________________________________________________________________________________Address:______________________________________________________________________________________City,State,Zip:_______________________________________________________________________________Homephone: ________________________________________________________________________________Workphone:_________________________________________________________________________________

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NCARTStandingDeviceEvaluationWorksheet

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PrimaryFundingSourceName: __________________________________________________________________________________________________________ID#:_____________________________________________Group#:_____________________________________________________Claimsphone:_________________________________________________________________________________________________Casemanager:_________________________________________________________________________________________________

SecondaryFundingSourceName: __________________________________________________________________________________________________________ID#:_________________________________________Group#:_______________________________________________________Claimsphone:__________________________________________________________________________________________________Casemanager:_________________________________________________________________________________________________

Consumer'sEmployment/SchoolInformationEmployer/school:____________________________________________________________________________________________Address:_______________________________________________________________________________________________________City,State,Zip:________________________________________________________________________________________________Title/Grade:___________________________________________________________________________________________________Supervisor/educator:________________________________________________________________________________________

II. PhysicalFindings

Diagnosis/Prognosis:_________________________________________________________________________________________Sex:________Height:___________Weight:____________Onsetofdisability________________________________Medicalhistory:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Chiefcomplaints/Presentingproblems:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

:



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FunctionalStatus:Ambulation:___None___Wheelchairformobility___Limited‐Deviceused:________________________WalkingDistance:_________________________Mildassist___Moderateassist___MaximumassistTransfer:___Independent___Dependent‐___Onepersonassist___TwopersonassistMethod:____________________________________________________________________________________________Activitiesofdailyliving:___Independent___Partialassist___DependentLivingenvironment:___Home___Apartment___Institution___Singlelevel___Multi‐level___Owns___RentsTransportation:___Car___Van___Publictransportation___Other___________________________________Cognitivelevel:___OnageLevel___Delayed/Impaired

___Understandssafetyofself&others___Developmental/Psycho‐SocialneedforstandingComments:________________________________________________________________________________________________Communication:___Verbal___Non‐verbal___AugmentativeCommunication‐Device______________________________________________________________________________________________________________________________Comments:________________________________________________________________________________________________PhysicalStatus:SittingBalance:___Good‐handsfreecapabilitytoweightshift___Fair‐handsfreeonly___Poor‐propped&handsupport____Dependent‐needsexternalsupportMuscleStrength:U/E___Normal____Reduced____NoneL/E___Normal____Reduced____NoneSittingPosture(unsupported):

Posteriorpelvictilt:___None___Fixed___Flexible___Other_____________________________________Anteriorpelvictilt:___None___Fixed___Flexible___Other______________________________________Pelvicobliquity:___None___Fixed___Flexible___Other_________________________________________Pelvicrotation:___None___Fixed___Flexible___Other__________________________________________Kyphosis:___None___Fixed___Flexible___Other_________________________________________________Lordosis:___None___Fixed___Flexible___Other_________________________________________________Scoliosis:___None___Fixed___Flexible___Other_________________________________________________Head/neckhyperextension:___None___Fixed___Flexible___Other____________________________Legabduction:___None___Fixed___Flexible___Other___________________________________________Legadduction:___None___Fixed___Flexible___Other___________________________________________


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Windsweeping:___None___Fixed___Flexible___Other_________________________________________Leglengthdiscrepancy:___NoneLeft‐_______inchesRight‐_______inchesOther:_____________________________________________________________________________________________________

Lowerextremityrangeofmotion(seated):Hipflexion(normal0˚to125˚):Left‐_______degreesRight‐_______degreesKneeextensionhipat90˚:Left‐_______degreesRight‐_______degreesAnkledorsi‐flexion:Left‐_______degreesRight‐_______degreesOther(e.g.hipsubluxation,ankleinversion/eversion,orthoticsused,etc.)_____________________________________________________________________________________________________________________________________

Tonalinfluences/reflexes:___Hypotonia___Hypertonia___Extensor___Flexor___ATNR___STNR___Positivesupport___Ankleclonus___Other____________________________________________________________________________________________________________________________________________________________________________________________

Skinintegrity:___Intact___Redarea___Openarea___Scartissue___HistoryofpressureulcersArea:___Ischialtuberosity___Coccyx___Spine___Other_______________________________________________________________________________________________________________________________________________________

Sensation:___Normal___Impaired___Non‐sensateLevel_____________________________________________Bowel:___Continent___Incontinent___Training___Constipation___Irregularity___Other_________________________________________________________________________________________________________________________Bladder:___Continent___Incontinent___Training___Current/historyofUTI____KidneyStones___Other________________________________________________________________________________________________________

StandingStatus:Descriptionofabilitytostand/bearweight‐__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________


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Isindividualonacurrentstandingprogram‐____Yes____NoIfyes,describeresults:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

TherapiesReceived:___PT___OT___Speech___Other____________________________________________

Other notes: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________

If item is Replacement: Current stander and when obtained-_______________________________________________________________________ Issues with current stander requiring replacement-_______________________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________

Would this be an Initial or Replacement standing device- ___Initial ___Replacement



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III.MeasurementsinSitting&Standing(seediagram)1.Seatsurface(thecontactpointofthebuttocksto)orStanding:

Left Right Standinga.PSIS b.Elbow c.InferiorScapulaAngle d.Axilla(Armpit) e.TopofShoulder f.TopofHead

2.Trunkdepth(backsurfacetofrontoftheribs)_________________________________________3.Seatdepth/thighlength(backsurfacetopoplitealangleofknee)____________________4.Backofkneetoheel(orweight‐bearingarea)__________________________________________5.Footlength(withshoes&AFO’sifapplicable)__________________________________________6.Trunkwidth(acrosschest)_______________________________________________________________7.Shoulderwidth_____________________________________________________________________________8.Hipwidth___________________________________________________________________________________9.Outerkneewidth(relaxed,withkneesapart)__________________________________________



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IV.StandingDevice(s)ConsideredDocumenteachstandingdeviceconsideredintheareasbelowandlistwhyitwasruledoutorwhyitisbeingchosenfortheconsumer.SinglePositionStandingFrameSystem(E0638)*Note:PositionofusemaybeproneORsupineORupright.PertinentFindings:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Transfermethod:___independent___one‐person___two‐person___patientliftrequiredSit‐to‐StandSystem(E0637)*Note:Positionofusetransitionsconsumerbetweensittingandstandingtoupright.PertinentFindings:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Transfermethod:___independent___one‐person___two‐person___patientliftrequiredMulti‐PositionStandingFrameSystem(E0641)*Note:SingledevicecanbeutilizedinanyONEofthesethreepositions:prone/supine/upright.PertinentFindings:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Transfermethod:___independent___one‐person___two‐person___patientliftrequiredMobileStandingFrameSystem(E0642)*Note:Anyoftheabovestandingsystemswiththeadditionofamobileoption.PertinentFindings:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Transfermethod:___independent___one‐person___two‐person___patientliftrequired


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ManualWheelchairAccessory,ManualStandingSystem(E2230)*Note:Manualstandingfeature,whichispartofamanualwheelchairbase(accessory).PertinentFindings:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Transfermethod:___independent___one‐person___two‐person___patientliftrequiredPowerWheelchairAccessory,PowerStandingSystem(E2301)*Note:Powerstandingfeature,whichispartofapowerwheelchairbase(accessory).PertinentFindings:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Transfermethod:___independent___one‐person___two‐person___patientliftrequiredOtherStandingDevice:___________________________________________________________________________________PertinentFindings:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Transfermethod:___independent___one‐person___two‐person___patientliftrequiredV.StandingDeviceRecommendedTypeofstanderneeded:___________________________________________________________________________________Manufacturer/Model:______________________________________________________________________________________TrialDate:____________________________________________________________________________________________________ConsiderationsandOutcomesofStandingDeviceTrial1.Doestheconsumerhaveconsistentaccesstothedevice(includingtransferconsiderationsandcaregiveravailability)?___YES___NO_____________________________________________________________________________________________________________________________________________________________________________________2.Isthepatientabletooperatethestanderindependently?___YES___NO____________________________________________________________________________________________________________________________________________




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3.Doesthestanderhaveadequatesupports,anteriorly,posteriorly,andlaterallytopositionthepersoninasymmetricalalignedstanding?___YES___NO________________________________________________________________________________________________________________________________________________________________4.Whatsupportandalignmentoptions/accessoriesarenecessarytoproperlypositiontheconsumer?___________________________________________________________________________________________________________________________________________________________________________________________________________________5.Doesthestanderhaveenoughadjustmenttoallowforindividualfitandallowforgrowthorbodychanges?___YES___NO_____________________________________________________________________________________________________________________________________________________________________________________________6.Isthisstanderappropriatefortheclient’shomeenvironmentortheenvironmentsinwhichitwillbeused?___YES___NO_______________________________________________________________________________________________________________________________________________________________________________________________7.Didtheconsumerremainmedicallystablethroughoutthetrial?___YES___NO_________________________________________________________________________________________________________________________________8.Additionalcommentstojustifystandingdevicetype:________________________________________________________________________________________________________________________________________________________________VI.SummaryAstandingdeviceisbeingrecommendedforthefollowingreasons(checkthoseapplicable):

___Improve/Maintainrangeofmotion:___CurrentIssue___Atrisk___Decreasejoint/musclecontractures:___CurrentIssue___Atrisk___Managementofatrophyinthetrunkandlegmuscles:___CurrentIssue___Atrisk___Improvestrengthtotrunkandlowerextremities:___CurrentIssue___Atrisk___Decreasemusclespasms:___CurrentIssue___Atrisk___Improve/Maintainboneintegrity/skeletaldevelopment:___CurrentIssue___Atrisk___Lessen/Managetheprogressionofscoliosis:___CurrentIssue___Atrisk___Managepressure(ulcers)throughchangingpositions:___CurrentIssue___Atrisk


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___Improvebowelfunctionandregularity:___CurrentIssue___Atrisk___Aidinkidneyandbladderfunctions:___CurrentIssue___Atrisk___Strengthencardiovascularsystemandbuildendurance:___CurrentIssue___Atrisk___Improvecirculation:___CurrentIssue___Atrisk___Reduceswellinginlowerextremities:___CurrentIssue___Atrisk___Improveindependencewithactivitiesofdailyliving:___CurrentIssue___Atrisk___Improvecognitiveandpsycho‐social:___CurrentIssue____Atrisk

Standingprogramrecommendations(incl.frequency/duration):_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Describeindetailthecurrentproblemsandassociatedcoststhisconsumermaybehavingduetotheabsenceofthestandingprogramlistedabove:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Evaluationcompletedby:________________________________________________________________Title:________________________________________________________________________________________Phone:_______________________________________________________________________________________Facility:_____________________________________________________________________________________Address:____________________________________________________________________________________Signature:___________________________________________________________________________________Date:_________________________________________________________________________________________

ThisEvaluationWorksheetwasdevelopedbytheNationalCoalitionforAssistiveandRehabTechnology(NCART)StandingDeviceWorkgroup.NCARTseekstoensurethat

individualswithdisabilitieshaveappropriateaccesstocomplexrehabtechnology(CRT)andrelatedservices.ForadditionalinformationregardingCRTvisitwww.ncart.us.


Standing technology should only be used under the guidance of a physician with recommendations for standing program protocol and any medical precautions. Standing programs should be monitored by the attending therapist. AMI maintains a policy of continual product improvement and reserves the right to change features, specifications, and prices without prior notification. Check with AMI for latest information. FORM FG100814 REVA Copyright © 2014 Altimate Medical, Inc. All rights reserved. Printed in the USA.

262 West 1st St • Morton, MN 56270, USA • 800.342.8968 • [email protected] • easystand.com

Nancy Perlich COTA, ATPReimbursement Specialist

[email protected]. 877.844.1172fax 952.937.0821

For Standing Devices - Amazon Web Services...Two funding resources we feel are particularly helpful...

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