Funding Forms

The journey to AAC begins with having the right paperwork you need to obtain your device.

Before you begin your submission, make sure you have the proper documentation. Regardless of the method of purchase, your funding source will require paperwork – be sure you have what you need to begin the process.

These are the documents that every submission, regardless of funding source or state of origin, requires. You’ll need to download and complete these in full.

Please note that some states require the use of a state specific form for Medicaid submissions and should be used in lieu of the Certificate of Medical Necessity (found at the link below). State specific forms are located in the State Documents tab.

Required Documents

Recipient's Medical Card
Provide a legible copy of the front and back of all medical cards; Medicaid, Medicare, Insurance.
Trial Device Program?

Did you obtain your device through the Trial Device Program?

If YES:

-  Post-Trial Device Program Form |  Post-Trial Device Program Form (En Espanol)
-  Assignment of Benefits (AOB) |  Assignment of Benefits (AOB) (En Espanol)
  - If Insurance, signed by primary insurance policy holder.
  - If Medicare, signed by client or witness if client is unable to sign.
  - If Medicaid, signed by client or witness if client is unable to sign or signed by a legal guardian if a minor.
  - Contact AAC Funding at 800.268.5224 with any questions.

If NO:

-  Client Information |  Client Information (En Espanol)
-  Assignment of Benefits (AOB) |  Assignment of Benefits (AOB) (En Espanol)
  - If Insurance, signed by primary insurance policy holder.
  - If Medicare, signed by client or witness if client is unable to sign.
  - If Medicaid, signed by client or witness if client is unable to sign or signed by a legal guardian if a minor.
  - Contact AAC Funding at 800.268.5224 with any questions.
AAC Evaluation
A completed AAC Evaluation must accompany all requests. These can be completed either within the Funding Toolkit or created externally and uploaded.
 Certificate of Medical Necessity
The Centers for Medicare & Medicaid Services (CMS) and some state Medicaids require the beneficiary to have a face-to-face examination with their physician less than 6 months prior to the written order for an Speech Generating Device (SGD). The physician must document that the beneficiary was evaluated and/or treated for a condition that supports the SGD. This documentation must be provided along with the CMN. If the client has more than one form of insurance, only complete this form once.

In addition to the required documentation from the previous tab, please be sure to include paperwork that indicates what device you are purchasing, accessories needed, etc.

Equipment Selection Sheets

PRC	Saltillo
 PRC Equipment Selection Sheet - Accent Products & Accessories	 NovaChat Selection Sheet
 PRC Equipment Selection Sheet - PRiO Products & Accessories	 TouchChat Express Selection Sheet
 PRC-Saltillo Via Pro Selection Sheet
 Mounting Selection Sheet
 PRC & Saltillo Switch Selection Sheet

Trial Device Program

Only needed if a trial is being requested.

Borrow a device through PRC-Saltillo's Trial Device Program
Mounting Selection Sheet for Trials 

If you are not submitting the device purchase as an insurance or Medicare/Medicaid claim, you can pay to trial a device using the forms below.

Non-funded Device Rental

PRC

Saltillo

Device Rental Form

Alabama	Read Me First – Alabama Medicaid Alabama Medicaid Referral Form Augmentative Communication Evaluation Team Qualifications Augmentative Communication Evaluation Report Communication Prosthesis Payment Review Summary Statement of Non-Affiliation/Non-Conflict
Alaska	Read Me First – Alaska Medicaid Certificate of Medical Necessity
Arkansas	Read Me First - Arkansas Medicaid Prescription & Prior Authorization Rquest for Medical Equipment (Excluding Wheelchairs & Wheelchair Components)
California	Read Me First – California Medicaid
Colorado	Read Me First – Colorado Medicaid
Connecticut	Read Me First - Connecticut Medicaid Outpatient Prior Authorization Request Form
Delaware	Read Me First - Delaware Medicaid Certificate of Medical Necessity
Florida	Read Me First – Florida Medicaid and MCOs School Concurrence
Georgia	Read Me First – Georgia Medicaid Funding Submission Cover Sheet and Checklist Durable Medical Equipment/Supplies Face-to-Face Encounter Certification EXAMPLE: Durable Medical Equipment/Supplies Face-to-Face Encounter Certification Certificate of Medical Necessity EXAMPLE: Certificate of Medical Necessity
Idaho	Idaho Medicaid SGD Supplemental Form
Illinois	Augmentative Communication Device Trial Summary
Indiana	Read Me First – Indiana Medicaid & MCOs Prior Authorization Request Form Augmentative Communication System Selection
Iowa	Read Me First – Iowa Medicaid Augmentative Communication System Selection
Kansas	Certificate of Medical Necessity
Kentucky	Read Me First – Kentucky Medicaid Certificate of Medical Necessity
Maryland	Read Me First – Maryland Medicaid Maryland State Department of Health and Mental Hygiene Prepayment Request Form
Maine	Read Me First – Maine Medicaid Requirements for Prior Auth InterQual: Speech generating device, synthesized speech, permitting multiple methods of message formulation and multiple methods of device access
Massachusetts	Durable Medical Equipment and Medical Supplies General Prescription and Medical Necessity Review Form
Minnesota	Read Me First – Minnesota Medicaid
Mississippi	Read Me First – Mississippi Medicaid and MCOs Certificate of Medical Necessity - Alert Signaler and Related Supplies
Missouri	Read Me First – Missouri Medicaid and MCOs
Montana	Montana Certificate of Medical Necessity Montana Medicaid Prior Authorization Request Form
Nebraska	Augmentative Communication Device Selection Report
Nevada	Read Me First – Nevada Medicaid Durable Medical Equipment - Nevada Medicaid
New Hampshire	Augmentative Alternative Communication (AAC) AIDS Funding Information Augmentative Alternative Communication (AAC) Equipment Safeguarding Plan Augmentative Alternative Communication (AAC) Equipment Trial Summary Augmentative Alternative Communication (AAC) Equipment Replacement Requests
North Carolina	Read Me First – North Carolina Medicaid Request for Prior Approval
North Dakota	Read Me First – North Dakota Medicaid Certificate of Medical Necessity
Ohio	Read Me First - Ohio Medicaid Certificate of Medical Necessity – Prescription Speech Generating Device (SGD) Initial Certification Request for Need Verification – Repair of Durable Medical Equipment (Other than Wheelchairs), Prostheses, or Orthotic Devices
Oklahoma	Oklahoma Health Care Authority Prior Authorization Request
Oregon	Read Me First – Oregon Medicaid Augmentative Communication Device Support Summary
Pennsylvania	Read Me First - Pennsylvania Medicaid Outpatient Services Authorization Request
Rhode Island	Read Me First – Rhode Island Medicaid Request for Prior Authorization for Durable Medical Equipment (DME) - Children Only
South Carolina	Read Me First – South Carolina Medicaid Certificate of Medical Necessity for Equipment/Supplies Certificate of Medical Necessity for Equipment/Supplies - Example
South Dakota	Durable Medical Equipment and Medical Nutrition Prior Authorization Request Form
Texas	Read Me First - Texas Medicaid and MCOs CSHCN Services Program Prior Authorization Request for Augmentative Communication Devices (ACDs) Form and Instructions Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form Instructions
Vermont	Durable Medical Equipment Ownership, Operation, and Maintenance Agreement Medical Necessity Form (Mnf): Orthotics, Prosthetics, Medical Supplies & Equipment For In-Home Use
Virginia	Read Me First – Virginia Medicaid Certificate of Medical Necessity: Durable Medical Equipment and Supplies
Washington	Read Me First – Washington Medicaid Speech Language Pathologist (SLP) Evaluation for Speech Generating Devices Health and Recovery Services Administration (HRSA) Prescription Form
Washington, D.C.	Read Me First - DC Medicaid Prior Authorization Request
West Virginia	Read Me First – West Virginia Medicaid WVMI Medicaid DME / Medical Supplies Authorization Request Form Certificate of Medical Necessity
Wisconsin	Read Me First – Wisconsin Medicaid Prior Authorization / Durable Medical Equipment Attachment (PA/DMEA)

Funding through Medicare will also require documentation. If you’re using this option to obtain a device, please download these documents to complete your submission.

Local Coverage Determination
LCD for Speech Generating Devices (L11524) documentation requirements: The patient’s medical records will reflect the need for the care provided. You may be asked to provide this documentation if requested by the paying source (Medicare). More information can be found on the CMS website by searching on L11524 Local Coverage Determination for Speech Generating Devices.

Download the document 

Supporting Documentation

 Client Bill of Rights

 Client Bill of Rights (En Espanol)

 Supplier Standards CMS 30

 Notice of Privacy Practices

 Notice of Privacy Practices (En Espanol)