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.

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.

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Please be sure to include an image or copy (JPG or PDF) of valid insurance cards with the completed forms/documents.

Forbes AAC
181 Illinois Ave. South
Mansfield, OH 44905

phone 419.589.7688
fax 419.589.5146

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Forbes AAC is a trade name of Forbes Rehab Services, Inc.