Minnesota Medicaid Funding Forms

Required Funding Forms

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.

Augmentative Communication Devices and Accessories Authorization Form

This form is required by Minnesota Medicaid when requesting authorization for augmentative communication devices and accessories.

 

Use the link above to access the form required by Minnesota Medicaid when requesting authorization for augmentative communication devices and accessories. You may get a message that your Adobe Acrobat Reader needs to be updated. If you are still unable to access the form try using a different browser such as Firefox.

 

You may need to open the file with the option that appears in the upper right corner of the browser that says "Open with different viewer". Click that button and a window will appear with two choices, 'Open with' or 'Save file'. Either choice will work as indicated by their respective commands.

Face-to-Face Notes

Minnesota Medicaid 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.

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.

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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
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.