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Your PRC and Saltillo Funding Source

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.

  1. Recipient's Medical Card
    Provide a legible copy of the front and back of all medical cards; Medicaid, Medicare, Insurance.
  2. Assignment of Benefits (AOB) and Client Information  
    Assignment of Benefits (AOB) and Client Information (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.

  3. Speech Evaluation
    A completed Speech Evaluation must accompany all requests. These can be completed either within the Funding Toolkit or created externally and uploaded.
  4. 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   Nova Chat and Chat Fusion Selection Sheet
  PRC Equipment Selection Sheet - PRiO Products & Accessories   TouchChat Express Selection Sheet
  Mounting Selection Sheet   Mounting Selection Sheet
  PRC & Saltillo Switch Selection Sheet

Device Rental

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.


Alabama
Alaska
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Illinois
Indiana
Iowa
Kansas
Kentucky
Maryland
Maine
Massachusetts
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Texas
Vermont
Virginia
Washington
Washington, D.C.
West Virginia
Wisconsin

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.

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).


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)