Tried & Failed Questionnaire

TRIED & FAILED QUESTIONNAIRE

Below is the tried and failed questionnaire. Most insurances request that you have tried and failed all of the less restrictive options before they cover a safety bed. Please make sure all have been tried and marked yes. If you mark No, your doctor will need to say in his notes why the less restrictive option was not tried.

Patient Name:(Required)

Patient DOB:(Required)

MM slash DD slash YYYY

Caregiver Email: (Required)

Note to parent: These methods and why they have failed must be discussed within a recent office visit/medical notes as well as the letter of medical necessity. If you have not discussed these with your doctor, please schedule an appointment and let us know so we can send you helpful information to share with the office.

Mattress on floor(Required)

Yes

Video/Auditory Monitor(Required)

Yes

Install Bed Rails(Required)

Yes

Gates/Window/Door Locks(Required)

Yes

Use a Helmet(Required)

Yes

Increase Medication:(Required)

Yes

Bed/Door Alarms(Required)

Yes

Environmental Modifications to Encourage Calming Behaviors and Sleep(Required)

Yes

Established Routines to Address Sensory Needs and/or Behavior Modifications To assist with improved naptime or nighttime behaviors and sleep(Required)

Yes

Caregiver First Name(Required)

Caregiver Last Name(Required)

Caregiver Signature(Required)

Date(Required)

MM slash DD slash YYYY

**FYI all insurance companies have specific requirements on what must be tried and failed. Please see the patient’s insurance policy for Safety Bed prior authorization medical necessity requirements.

Phone Number:(Required)