Speech Evaluation Report Guidelines

An Addendum to this form must contain a description of the repair that is needed and state why the repair is medically necessary.

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

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 also contains the Return Policy.

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.

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.