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Funding Forms

Yet neither AAC/AT assessment or tools and instruction were provided to him. The IEP team’s concerns and recommendations highlight the need for additional assessment and appropriate services in the areas of AAC and AT, and his current IEP is inadequate to protect my child’s right to a FAPE in the least restrictive environment (LRE). With over 50 years of experience in augmentative and alternative communication (AAC) PRC-Saltillo is pleased to offer this unique online resource. We have made our service even better with all the new features and a lower price. For just $19.95 a year, you will have access to all of these valuable resources. There is a wide variety of technology specifically created for people who are Deaf, Hard of Hearing, Deaf-Blind and Speech-Impaired. The Division of Services for the Deaf and Hard of Hearing (DSDHH) does not endorse any products or companies listed below. PrAACtical AAC supports a community of professionals and families who are determined to improve the communication and literacy abilities of people with significant communication difficulties. It was founded in 2011 by two SLP professors, Carole Zangari and the late Robin Parker, around a shared passion for AAC. Equipment - CAYA maintains a loan bank of AAC devices and provides technical support services for those devices. Training and Resources – individualized training, small group sessions and large group workshops will be provided as necessary. Online modules and resource packages are also offered through the SET-BC Learning Centre.

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

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

Aac Equipment Sitesaac Resources Management

Saltillo

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).

Supporting Documentation

Client Bill of Rights

Client Bill of Rights (En Espanol)

Supplier Standards CMS 30

Aac Equipment Sitesaac Resources List

Notice of Privacy Practices

Notice of Privacy Practices (En Espanol)

Aac Equipment Sitesaac Resources Inc