VT Medicaid Forms
Medicaid SGD Evaluation Form
by Department of Vermont Health Access
Required evaluation form for requesting Speech Generating Device to be funded by Vermont Medicaid.
The downloaded document Includes the following:
- evaluation form
- baseline/endline checklist
- prescription
- DME Maintenance Agreements
To find the link, scroll down the page till you see the Augmentative Communication Device link.
VT Medicaid Medical Necessity Form
by Department of Vermont Health Access
When requesting a speech device from VT Medicaid, the applicant’s Primary Care Physician must complete this form of medical necessity.
Application Process
The materials below have been created by the Vermont I-Team’s AAC Consultants to help us guide teams through communication device trials. They specifically reflect Vermont Medicaid’s device funding requirements. Also, because we pair them with AAC Consultation services there may be individualized needs or steps that are not fully captured in the documentation alone.
SGD Trial Introduction
Short introduction explaining how the trial usually unfolds.
VT Medicaid Required Documents Chart
Chart of what docs are required for different situations (e.g. replacement, dedicated vs iPad).
SGD Trial Documentation
list of documentation associated with the trial
Trial Roles and Responsibilities
App and Device Features to Consider
Detailed list of software and hardware options and features to consider when selecting a device.
SGD Baseline / Endline Document
Required form for VT Medicaid evaluation, this shows the changes in observations of abilities between the start and the end.
SGD Implementation Plan
Condensed version of many of the elements teams need to think about for the implementation of the device.
Data Charts
SGD Trial Data Chart
Form for planning the trial contexts, selecting vocabulary, and setting up the data collection system.
SGD Trial Planning and Data Documents
Collection of documents related to planning trial contexts and collecting data.