SGD Mount Documentation

Patient Name:*

Date of Birth:*

Diagnosis:*

Ambulatory Status:*

Non-Ambulatory Status:*

Upper Extremity Status:

Paralysis/Paresis:*

Describe patient limitations, with regard to holding the SGD and operating it simultaneously:*

This request is medically necessary for the following reasons:*

The mount will allow this patient to have access to communication throughout his/her day in order to communicate wants, needs, symptoms, thoughts, and ideas
The mount will, or is reasonably expected to, reduce or ameliorate the physical, mental, or developmental effects of an illness, injury, or disability, such as social isolation or lack of independence
The mount will assist the individual to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the individual and those functional capacities that are appropriate for individuals of the same age

Signature of Preparer*

Date*

Printed Name of Preparer*

Professional Title*