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.
Contact AAC Funding at 800.268.5224 with any questions.
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.
| PRC Equipment Selection Sheet|| Nova Chat and Chat Fusion Selection Sheet|
| Mounting Selection Sheet|| TouchChat Express Selection Sheet|
| Mounting Selection Sheet|
| PRC & Saltillo Switch Selection Sheet|
Only needed if a rental is being requested. Individual accepting responsibility of equipment must sign and provide social security number. If NuEye is requested, must provide valid credit card number.
Your state may or may not have additional forms to complete. Look here to find out if you need to complete additional paperwork, depending on the type of funding requested.
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.
Physician's Progress Notes
The Centers for Medicare & Medicaid Services (CMS) require that the physician provide progress notes from the face-to-face examination for the speech generating device (SGD) and accessories. The physician must document that the beneficiary was evaluated and/or treated for a condition that supports the medical necessity of the SGD and accessories. These progress notes must accompany the CMN. The progress notes needs to be signed by a PECOS certified physician.
Medicare Advance Beneficiary Notice (if applicable)
AAC Funding will send this form to the beneficiary if its needed. The Advanced Beneficiary Notice is used if it is determined that Medicare will not pay for an item.
Should your device require service, if repair is planned to be paid for by private insurance, Medicaid or Medicare, then check here first to obtain any documents you’ll need to facilitate the repair.
Prescription from Physician
List specific device to be repaired.
Statement of Abuse or Neglect
Statement written by the SLP stating that the device repair is not from Abuse or Neglect by the client.
Repair Evaluation Form
This form may be used instead of the Letter of Recommendation from a Speech Language Pathologist (SLP).