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DUPLICATE Medicaid Funding Forms

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Required Funding Forms

These forms are required by your state’s Medicaid program in addition to the standard funding forms listed below. Please make sure to download all forms as a PDF and fill in the forms electronically. Save as needed before submitting to Forbes AAC.

Read Me First - Alabama Medicaid

If the client has Alabama Medicaid, this is recommended as to the purchase of equipment and should be read first to provide a brief background on the details.

Alabama Medicaid Referral Form

Alabama Medicaid Referral Form 362.

Augmentative Communication Evaluation Team Qualifications

Alabama Augmentative Communication Evaluation Team Qualifications.

Augmentative Communication Evaluation Report

Alabama Augmentative Communication Evaluation Report.

Communication Prosthesis Payment Review Summary

Alabama Communication Prosthesis Payment Review Summary.

Statement of Non-Affiliation/Non-Conflict

Alabama Statement of Non-Affiliation/Non-Conflict.

Augmentative Communication Device Evaluation Report Form

Alabama Augmentative Communication Device Evaluation Report Form.

If the client has Medicare as an additional funding source, please be advised that Face-to-Face notes must be completed is addition to the standard funding paperwork.

Standard Funding Forms

The forms listed below must be received to complete your funding packet request. Once we have received all of the listed items, a funding expert will review your documentation to determine if any alterations are required prior to submission. We encourage all of our customers to reach out to us with any questions that you may have! NOTE: Spanish forms are available for the Client Information Form, the Feature Unlock Key and the Release of Information (ROI) and Assignment of Benefits Form (AOB).

Order Forms

All funding packets begin with a price quotation. You can customize your AAC device by selecting a color, AAC app, keyguard, mounting options and other accessories.

Client Information Form

Gathers client information required by funding providers. All information will remain confidential.

Prescription/Certificate of Medical Necessity (CMN)

The completed prescription must be signed by your primary care physician. Please also visit the state-specific download section to see if any alternative or additional documents exist.

Release of Information (ROI) and Assignment of Benefits Form (AOB)

Your signature on this form authorizes Forbes Rehab Services, Inc. to release medical information to your insurance companies and to obtain prior authorizations and payment from your insurance company for services and equipment.

Place of Service Form

This form documents the client’s place of service (private residence, skilled nursing facility, etc.)

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Feature Unlock Key Form

This form is required to be filled out and signed prior to purchasing a Feature Unlock Key. The Feature Unlock Key allows users who have dedicated speech generating devices to access capabilities of their device that extend beyond voice output, emailing, texting or making phone calls as required by CMS.

Speech Evaluation Report Guidelines

This report must be written by a licensed speech-language pathologist. 

AAC Speech Evaluation Template

This comprehensive, fillable, speech evaluation template covers required reporting elements point by point. Use as is or as a template for your own speech evaluation report. A comprehensive AAC evaluation is a required element in the funding process. You will need to be approved as a member to the Forbes AAC web site to get access to this important and valuable tool. Click on the link to get started.

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