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Funding Downloads

Welcome to the Funding Downloads Section!

Here, you can download forms and templates that are required in your completed Funding Packet.

 

Our funding downloads are organized into the following sections:

 

Standard Funding Forms: In the majority of cases, these forms are required for ALL Funding Packets regardless of the funding source. Be sure to download, complete, and return these forms with your completed funding packet.

 

Funding Source-Specific Forms: In some cases, a funding source will require either and additional form, or an alternative form be used in rather than the Standard Funding Forms. Be sure to visit this section to see if any of these downloads apply.

 

 

If you have any questions, our funding experts are standing by, ready to help!

Call us today toll free at 1-888-884-2190 

 

Standard Funding Forms
The forms below are required for ALL funding Packets.  
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The Funding Checklist gives you an overview of all the documents required for a complete and ready-to-submit, funding packet.
 

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The Client Information form is a starting point for any funding packet. It gathers client information required by the funding provides.
 

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This completed prescription must be signed by the primary care physician. Please also visit the state-specific download section to see if any alternative or additional documents exist.
 

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Signature on this form authorizes Forbes Rehab Services, Inc. to release medical information to your insurance companies and to obtain prior authorizations and payment from your insurance company for services and equipment.


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Completion of this form is required for all funding sources. It documents the client’s place of residence (private residence, skilled nursing facility, etc.)
 

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Feature Unlock Key Form

This form is required to be filled out and signed prior to purchasing a Feature Unlock Key.  The Feature Unlock Key allows users who have dedicated speech generating devices to access capabilities of their device that extend beyond voice output, emailing, texting or making phone calls as required by CMS.

 

Funding Source-Specific Forms
These additional forms are required for the funding sources listed below.
Alabama Medicaid:

PDF IconAugmentative Communication Device (ACD) Evaluation Report Form (480)
Form 480 is designed to expedite the review process for ACDs. These devices require prior authorization (PA). The form includes all the elements that the reviewer requires to determine that medical necessity criteria are met.

 
Florida Medicaid:
 

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If the Client is of school age, and has Florida Medicaid, completion of this form is also required.

Kentucky Medicaid:


CMN – Required form for Kentucky Medicaid to be signed by physician.

 

Idaho Medicaid:


SGD Supplemental Form – Idaho Medicaid requires this supplemental form to be filled out for SGD application.

Illinois Medicaid:


IL Medicaid Funding Checklist - This funding checklist provides an overview of the documents required to receive funding for a speech-generating device by Illinois Medicaid. Funding sources have strict guidelines; a comprehensive Funding Packet must be compiled prior to submittal. Missing information will result in processing delays.

 

 

Client Assessment ReportThis form is the Speech Evaluation Report required by Illinois Medicaid. It must be completed and signed by a qualified SLP.

 

 

Client Trial Summary – This summary is required by Illinois Medicaid to record each augmentative communication device trial. Use one form per device trial, i.e. if three devices were trialed then three summary forms are required.

 

Letter of Medical Necessity – This letter is required by Illinois Medicaid and must be signed and dated by the physician prior to all other paperwork.

 


 

Prescription – Use this prescription form when Medicare is not a source of funding. A letter of medical necessity from the doctor is also required.

 

Indiana Medicaid:


Medical Clearance Form - If the client has Indiana Medicaid, this form is required for the purchase of equipment along with the other documents.

PA form – Required to be signed by physician for Indiana Medicaid. With assistance in completing, please contact our funding department.

 

 

Missouri Medicaid


Welcome Missouri Medicaid recipients! FRS is a Medicaid provider for the state of Missouri and can provide funding support for clients in need of AAC devices. Click here to access our forms and other helpful resources such as report writing guidelines and samples.

Ohio Medicaid:

Ohio Medicaid Initaial Certification PDF iconOhio Medicaid  - Initial Certification

If the client has Ohio Medicaid as their only funding source, this form is required for the purchase of equipment. If another funding source may be used, please call our office prior to completing this document to determine if this is the proper format to be used. When using this form, it is to be completed and then signed by all team members including the physician prescribing the equipment.

Texas Medicaid:

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If the client has Texas Medicaid, this form is required for the purchase of equipment. It is to be completed and then signed by the physician prescribing the equipment.
Washington Medicaid:

If the Client has Washington Medicaid, this prescription form is used instead of the Prescription/Certificate of Medical Necessity provided in the Standard Funding Forms. This Rx is to completed and then signed by the physician prescribing the equipment.
 
This form is the Speech Evaluation Report required by Washington Medicaid. It must be completed by a  qualified provider and then signed by both the evaluating SLP and the Physician prescribing the equipment.

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