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Funding Packet for Medicare and Private Insurance

Required Documents for Insurance and Medicare Reimbursement
 
The provider must receive these items prior to delivering equipment to the client.  This applies to purchases, rentals, and repairs.
 
Click on underlined text below to access form(s)
Client Information Form    Patient Responsibility
Copy of Medicare Card Patient Responsibility
Copy of All Insurance Cards (Front and Back) Patient Responsibility
Assignment of Benefits, signed by client Patient Responsibility
Consent Form Patient Responsibility
Disclosure of Medical Information Patient Responsibility
Checklist for Speech Evaluation Report    Child Evaluation    Adult Evaluation Speech Therapist's Responsibility

Physician's Prescription   Certificate of Medical Necessity   

                                      Prescription for Durable Medical Equipment

                                                                                

 

Must include patient's name, Dr.'s UPIN, Diagnosis, Length of Need, Itemized List of Equipment, signed and dated

by treating physician (dated after date of evaluation)

 Physician Responsibility