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2018 AAC Application for Florida Residents with ALS

 

Application for Augmentative and Alternative Communication (AAC) Assistance

The Florida Chapter Care Services will help you navigate the insurance system for coverage of a computer communication device and can assist you with the following:  

  • User friendly communication boards
  • Software and Access Equipment and Resources to adapt your commercial computers and phones
  • Loaner dedicated communication devices 

PLEASE NOTE: This application must be filled out by a health care professional. Any information provided in this survey will NOT be submitted to a third party (i.e., insurance company) or be entered into a medical record. Health care providers, please answer questions to the best of your ability. We greatly appreciate your time and effort.

Before receiving a computer device through the Chapter loaner program, you must have a non-computer based communication system in place. Using computer communication devices is a choice that should be made early in the disease progression. In the later stages of ALS there is not always enough energy to learn how to use a complex device. Training and appropriate set up of a computer communication device is imperative for successful use of a loaner device. It is also necessary for both the person living with ALS and the primary family caregiver to be strongly motivated to use a device.

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Loaner communication equipment may be available for people living with ALS who are Florida residents and registered with the Florida Chapter when:

  • The person with ALS has no medical insurance or has limits on medical equipment in an insurance policy
  • The person with ALS is in a nursing home, hospice, or hospital and cannot access health insurance for the device
  • The person with ALS has no co-insurance and cannot afford the co-pay on the communication device
  • There is a delay in the delivery of an approved and ordered device 

A Loaner Agreement must be completed to borrow AAC equipment.

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To apply for assistance, please complete the following:

*1.  


*2.  


*3.

(Maximum response 255 chars, approx. 5 rows of text)

*4.


*5.


*6.

(Maximum response 255 chars, approx. 5 rows of text)

7.

(Maximum response 255 chars, approx. 5 rows of text)

*8.
Question - Required - The person with ALS is currently receiving the following:
Please make between 1 and 4 selections from the choices below.

*9.

(Maximum response 255 chars, approx. 5 rows of text)

*10.


*11.

(Maximum response 255 chars, approx. 5 rows of text)

*12.
Question - Required - Please describe the insurance coverage the person with ALS currently holds: (Please select all that apply)
Please make at least 1 selection from the choices below.

*13.


14.

(Maximum response 255 chars, approx. 5 rows of text)

*15.


*16.
Question - Required - The language spoken by the person with ALS is:
Please make up to 4 selections from the choices below.

*17.
Question - Required - How experienced is the person with ALS with computers?
Please make up to 4 selections from the choices below.

*18.


*19.


 

FUNCTIONAL STATUS (in regards to SGD access):

*20.
Question - Required - Rate the status of the upper limbs of the person with ALS:
Please make 2 selections from the choices below.

*21.
Question - Required - Rate the status of the lower limbs of the person with ALS:
Please make 2 selections from the choices below.

*22.

*23.
Question - Required - Describe the mobility status of the person with ALS:
Please make between 1 and 7 selections from the choices below.

*24.
Question - Required - Rate the head control of the person with ALS:
Please make 1 selection from the choices below.

*25.
Question - Required - Rate the upper body strength of the person with ALS:
Please make 1 selection from the choices below.

*26.
Question - Required - Based on your professional opinion, please select all that apply when describing the patient's pitch:
Please make at least 1 selection from the choices below.

*27.
Question - Required - Based on your professional opinion, please select all that apply when describing the patient's prosody:
Please make at least 1 selection from the choices below.

*28.
Question - Required - Based on your professional opinion, please select all that apply when describing the patient's resonance:
Please make at least 1 selection from the choices below.

*29.
Question - Required - Based on your professional opinion, please select all that apply when describing the patient's loudness:
Please make at least 1 selection from the choices below.

*30.
Question - Required - Based on your professional opinion, please select all that apply when describing the patient's articulation:
Please make at least 1 selection from the choices below.

*31.
Question - Required - Based on your professional opinion, please select all that apply when describing the patient's vocal quality:
Please make at least 1 selection from the choices below.

*32.
Question - Required - Based on your professional opinion, please select all that apply when describing the patient's respiration:
Please make at least 1 selection from the choices below.

*33.
Question - Required - Based on your professional opinion, please select all that apply when describing the patient's diadochokinetic performance:
Please make at least 1 selection from the choices below.

*34.  


*35.

(Maximum response 255 chars, approx. 5 rows of text)

*36.

*37.

38.

39.

*40.  


*41.  


 

PLEASE NOTE: This application must be filled out by a health care professional. Any information provided in this survey will NOT be submitted to a third party (i.e., insurance company) or be entered into a medical record. Health care providers, please answer questions to the best of your ability. We greatly appreciate your time and effort.

Release of Information and Assumption of Risk, Waiver and Release of Liability, and Indemnification Agreement

I authorize The ALS Association Florida Chapter to communicate with, obtain information from, and provide information to any service provider, including medical providers and insurance companies, for the purpose of discussing or arranging the services I request or need regarding the CARE Assist program.

In consideration of The ALS Association Florida Chapter ("The ALS Association Florida Chapter") furnishing, discounts and grants for equipment or ALS medically related expenses and services prescribed or recommended by an ALS health care professional, as part of my participation in the CARE Assist Program, I agree as follows:

ASSUMPTION OF RISK - I understand that my participation in the CARE Assist Program contemplates the receipt of discounts and grants from The ALS Association Florida Chapter that may be used for, but is not limited to, my receipt of services, use of equipment, or operation of a vehicle. I understand and acknowledge that: (a) risks and dangers exist in my receipt of services, use of equipment, or operation of a vehicle that derive from the discounts and grants provided to me by The ALS Association Florida Chapter; (b) my receipt of services, use of equipment, or operation of a vehicle that derive from the discounts and grants provided to me by The ALS Association Florida Chapter may result in injury or death either to me or a third party; (c) these risks and dangers may be caused by the actions, inaction or negligence of either me or a third party; and (d) there may be risks not known to me or not reasonably foreseeable.

WAIVER AND RELEASE OF LIABILITY - I forever release, discharge and acquit the ALS Association Florida Chapter from any and all claims, demands, suits, or causes of action of any nature which I may have against The ALS Association Florida Chapter for damages, costs, expenses, attorneys' fees, damages to or loss of property, or personal injury, or death or any other losses or damages whatsoever that arise out of any act, occurrence, or accident in any way connected with my participation in the CARE Assist Program.

INDEMNIFICATION - I agree to defend, indemnify and hold harmless The ALS Association Florida Chapter from and against any claims, demands, suits, or causes of action of any nature by any third party for damages, costs, expenses, attorneys' fees, damages to or loss of property, or personal injury, or death or any other losses or damages whatsoever that arise out of any act, occurrence, or accident in any way connected with my participation in the CARE Assist Program.

MISCELLANEOUS - 

  • I agree that this Agreement shall be interpreted and enforced in accordance with Florida law.
  • I agree that if one or more paragraph(s) of this Agreement are ruled invalid or unenforceable, such invalidity or unenforceability
  • shall not affect any other provision of the Agreement, which shall remain in full force and effect.
  • I agree that each provision of this Agreement is intended to be severable. If any term or provision of this Agreement is illegal or invalid for any reason whatsoever, such illegality or invalidity shall not affect the validity or legality of the remainder of this Agreement.
  • As used in this Agreement, I understand the term “I,” "me," or "my" shall include my heirs, personal representatives, assigns, and agents. I understand that this Agreement binds my heirs, personal representatives, assigns, and agents.
  • As used in this Agreement, I understand the term “The ALS Association Florida Chapter” shall mean The ALS Association Florida Chapter, as well as The ALS Association Florida Chapter's officers, trustees, employees, volunteers, agents, representatives, and affiliated organizations.
  • As used in this Agreement, I understand that the singular shall include the plural and vice versa; the terms “and” and “or” shall be both conjunctive and disjunctive; and the term “including” means “including without limitation.

I have read the above and fully understand 1.) The purpose, procedures, requirements, and 2.) This assumption of risk, waiver and release of liability, and indemnification agreement. I understand that I am giving up substantial rights, including my right to sue the ALS association Florida chapter, and its officers, trustees, employees, volunteers, agents, representatives, and affiliated organizations. I also understand that this agreement binds heirs, my personal representatives, assigns, agents, and me. I acknowledge that I am signing this agreement freely and voluntarily, and intend by my signature to be a complete and unconditional release of liability. I assert that my participation in the care assist program is voluntary and I knowingly assume all such risks.

*42.
Question - Required - By selecting "YES", I am agreeing to the above Release of Information, Assumption of Risk, Waiver and Release of Liability, Indemnification Agreement and general terms of the grant program.

 

This form is an application, not a survey. By clicking on the Submit button, you are applying for Communication Equipment Assistance and your application is being sent to The ALS Association Florida Chapter Care Services administrative office, 3242 Parkside Center Circle, Tampa, FL 33619, 1-888-257-1717.

For more information, please contact Medical Equipment Director,Jessica Bianchi, JBianchi@alsafl.org 1-888-257-1717 ext. 122 or Programs Coordinator, Sabela Miralles, SMiralles@alsafl.org 1-888-257-1717 ext. 113.
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