Wisconsin 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.
Wisconsin 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. The documentation of the visit must be a clearly titled, separate and distinct section of, or a clearly titled addendum to the prescription. The chart notes or office visit notes must contain:
Date of the face-to-face examination
Name and credentials of the physician or NPP who conducted the face-to-face examination for the SGD
The clinical findings that support the client’s need for the SGD
Signature of prescribing physician or NPP that conducted the face-to-face examination
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! 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).
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.