Supporting Documents

Below are links to our Client Bill of Rights, Supplier Standards, and Privacy Practices for your reference.

• Client Bill of Rights
• Client Bill of Rights (en español)
• Supplier Standards CMS 30
• Notice of Privacy Practices
• Notice of Privacy Practices (en español)
• Medical Release Form
• Medical Release Form (en español)
• Letter to Physician
• Letter to Physician (en español)

State Documents

• 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
• Arizona
  • Read Me First – Arizona Medicaid
• Arkansas
  • Read Me First – Arkansas Medicaid
  • Prescription & Prior Authorization Request 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
  • Read Me First – Illinois Medicaid
  • Augmentative Communication Device Trial Summary
  • Addendum Sample for Recommending Purchase After Trial
• 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
• Louisiana
  • Read Me First – Louisiana Medicaid
• 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
• Maryland
  • Read Me First – Maryland Medicaid
  • Maryland State Department of Health and Mental Hygiene Prepayment Request Form
• Massachusetts
  • Read Me First – Massachusetts Medicaid
  • Durable Medical Equipment and Medical Supplies General Prescription and Medical Necessity Review Form
• Michigan
  • Read Me First – Michigan Medicaid
• Minnesota
  • Read Me First – Minnesota Medicaid
• Mississippi
  • Read Me First – Mississippi Medicaid and MCOs
  • MS Medicaid CMN
    • EXAMPLE: MS Medicaid CMN
  • Molina CMN
    • EXAMPLE: Molina CMN
• 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
  • Recipient Attestation
• New Hampshire
  • Read Me First – New Hampshire Medicaid
  • 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
• New York
  • Read Me First – New York Medicaid
• North Carolina
  • Read Me First – North Carolina Medicaid
  • Request for Prior Approval
• North Dakota
  • Read Me First – North Dakota Medicaid
• Ohio
  • Read Me First - Ohio Medicaid
  • Certificate of Medical Necessity – Prescription Speech Generating Device (SGD) Initial Certification
• 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 Title XIX Medical Supplies Physician Order Form
• Vermont
  • Read Me First – Vermont Medicaid
  • 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
    • How to Complete the Certificate of Medical Necessity (example)
• Washington
  • Read Me First – Washington Medicaid
  • Speech Language Pathologist (SLP) Evaluation for Speech Generating Devices
  • Prescription Form
• Washington, D.C.
  • Read Me First - DC Medicaid
  • Prior Authorization Request
• West Virginia
  • Read Me First – West Virginia Medicaid
  • Certificate of Medical Necessity
• Wisconsin
  • Read Me First – Wisconsin Medicaid
  • Prior Authorization / Durable Medical Equipment Attachment (PA/DMEA)

No documents available for this state.

Medicare Documents

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 document

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.

Filing Offline?

Please complete and include the necessary Equipment Selection Sheets(s) with your submission.

• Accent Products and Accessories
• NovaChat Products and Accessories
• Via Products and Accessories
• Mounting Products
• Switches and Switch Mounts

Non-funded Device Rental Contracts

If you need to rent a device from us that does not involve your insurance, please use the following forms.

• PRC-Saltillo Paid Rental Contract
• PRC-Saltillo Paid Rental Contract (En Espanol)