Unified Community Connections

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Unified Community Connections
No Boundaries Assistive Technology Center

REFERRAL FORM

PATIENT INFORMATION
REASON FOR REFERRAL
PHYSICIAN INFORMATION
INSURANCE INFORMATION
Please note: Unified’s No Boundaries Assistive Technology Center does not accept Insurance, Medicare, or Medical Assistance as forms of payment for assessments, therapy, or training. Information below should be completed for Patients receiving a Communication Device Assessment to assist in procurement of the communication device:
Please note: Unified’s No Boundaries Assistive Technology Center does not accept Insurance, Medicare, or Medical Assistance as forms of payment for assessments, therapy, or training. Information below should be completed for Patients receiving a Communication Device Assessment to assist in procurement of the communication device:
PAYMENT INFORMATION
FEE SCHEDULE
Fees
Augmentative and Alternative Communication Assessment/ $300.00 for the initial assessment appointment
Assistive Technology/Computer Access Assessment/ $100 per hour if a second session is warranted
Speech & Language Assessment  
   
Augmentative and Alternative Communication Set-up/Therapy/Training $125.00 per hour
Assistive Technology/Computer Access Set-up/Therapy/Training $125.00 per hour
Speech & Language Therapy $125.00 per hour
Presentations/Training $125.00 per hour (does not include the cost of any requested presentation materials)
   
Travel fees for any service occurring outside of Unified’s main office: $40.00 per hour

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