Community First Choice Option (CFCO)

ASSISTIVE TECHNOLOGY DESCRIPTION AND COST PROJECTION FORM

12/19/2018

Consumer Name: __________________________________________________________. CIN: _________________

1. Describe the Assistive Technology being requested:
   
   ______________________________________________________________________________
   
   ______________________________________________________________________________
2. Explain how the Assistive Technology will help contribute toward the consumer´s health and welfare.
   
   ______________________________________________________________________________.
   
   ______________________________________________________________________________.
3. Attach all assessments and bids. Identify the selected bid.
   
   ______________________________________________________________________________.
   
   ______________________________________________________________________________.

Enrollee/Recipient Signature: ______________________________________________________________ Date: ____________

Legal Guardian/Representative (as applicable) Name: ____________________________________________________________

Legal Guardian/Representative Signature: ____________________________________________________ Date: ____________

Assistive Technology Provider Name: _________________________________________________ Provider ID# ______________

Contact Person Name: ________________________________________________________________________

Contact Person Signature: __________________________________________________________________ Date:

Care/case manager Name: ____________________________________________________________________

Care/case manager Signature: _____________________________________________________________ Date: ____________

Developmental Disabilities Regional Office (DDRO) or Local Department of Social Services (LDSS) Representative:

_____________________________________________________________________________

_____________________________________________________________________________

Assistive Technology Approved: ☐

DDRO or LDSS Representative Signature: ___________________________________________________ Date: ____________