Medicare Funding Forms

Medicare Funding Forms

These forms are required in addition to the Standard Funding Forms listed below.

Place of Service Form

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

Face to Face Notes

Medicare requires that the client have a face-to-face examination with their physician no more than 6 months prior to the written order for the speech generating device (SGD). The physician must document that the client was evaluated and/or treated for a condition that supports the SGD. This documentation (chart notes or office visit notes) must be provided along with the written order for the SGD. 

AAC Evaluation Report

Specific statements and information are required for an AAC Evaluation Report to be Medicare-compliant. SLPs may write reports in their preferred format, but the template below is recommended as it contains all Medicare-required prompts. This Report is a MS Word document.

Standard Funding 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.

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 also contains the Return Policy.

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.

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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
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.