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.

To download the Prior Authorization/Durable Medical Equipment Form, click on the button.

This form needs to be completed per WI Medicaid requirements.                                                                             

Click on the following link for instructions regarding the required  prior authorization form;

Prior Authorization/Durable Medical Equipment Attachment (PA/DMEA) Completion Instructions

Face-to-Face Notes

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!

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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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.