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

Trial Device Program

Only needed if a trial is being requested.

• Borrow a device through PRC-Saltillo's Trial Device Program

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

• Download the Trial Evaluation/Paid Rental Contract form
• Contrato de Evaluacion de Prueba

Saltillo

• Device Rental Form

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  

Other documents:

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).

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.

•    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.
•    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.