Indiana Medicaid Funding Forms

Required Funding Forms
Required Funding Forms

These forms are required by your state’s Medicaid program in addition to the standard funding forms listed below.

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.

If the client has Indiana Medicaid, this form is required for the purchase of equipment along with the other documents.

Required to be signed by physician for Indiana Medicaid. With assistance in completing, please contact our funding department.

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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!

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.

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

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.

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.

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

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Additional Requirements
  • OT Report or Letter: A licensed Occupational Therapist must write a report or letter that assesses the modes of accessing the device. The report must include the method of selection and a statement of the client’s fine motor abilities as related to accessing the device, positioning and scanning. This information may be included in the AAC Evaluation if that document is signed by the OT.

  • PT Report or Letter: A licensed Physical Therapist must write a report or letter that assesses gross motor skills and any accommodations needed to access the device. This information may be included in the AAC Evaluation if that document is signed by the PT.

Contact your local funding specialist

Forbes AAC has a fully staffed funding team ready to assist you. We dedicate associates to specific geographic regions so that you can contact a local expert throughout the funding process.

 

By dedicating our experts on a regional basis, we provide you with a trusted partner to maximize our clients' likelihood for obtaining funding.

 

Forbes AAC
49 Illinois Ave. South
Mansfield, OH 44905

toll free phone 1.888.884.2190
toll free fax 1.877.884.9383

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