Pennsylvania 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.
Pennsylvania Read This First Form
Please read this form first to get the funding process going for Pennsylvania.
Outpatient Service Authorization Request MA 97
Complete and submit this form with your AAC Speech Evaluation Report.
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! NOTE: Spanish forms are available for the Client Information Form, the Feature Unlock Key and the Release of Information (ROI) and Assignment of Benefits Form (AOB).
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.
Prescription/Certificate of Medical Necessity (CMN)
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.
Release of Information (ROI) and Assignment of Benefits Form (AOB)
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.
Speech Evaluation Report Guidelines
This report must be written by a licensed speech-language pathologist.
AAC Speech Evaluation Template
This comprehensive, fillable, speech evaluation template covers required reporting elements point by point. Use as is or as a template for your own speech evaluation report. A comprehensive AAC evaluation is a required element in the funding process. You will need to be approved as a member to the Forbes AAC web site to get access to this important and valuable tool. Click on the link to get started.
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.