Funding Documents for Repair
Please make sure to download all forms as a PDF and fill in the forms electronically. Save as needed before submitting to Forbes AAC for the repair.
Before filling out any forms, please contact Support at 419.589.7688 option 2 to see if the devise is still under warranty.
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.
This form documents the client’s place of service (private residence, skilled nursing facility, etc.)
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.
Please be sure to include an image or copy (JPG or PDF) of valid insurance cards with the completed forms/documents.