Funding List

Augmentative Communications Consultants, Inc.

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)

Augmentative Communication Consultants, Inc. Supplier Standards	Patient Responsiblity
Glossary of Medical Terms	Patient Responsiblity
Information Letter for Applicant	Patient Responsiblity
Patient Information Form	Patient Responsiblity
Copy of Medicare Card	Patient Responsiblity
Copy of All Insurance Cards (Front and Back)	Patient Responsiblity
Assignment of Benefits, signed by client	Patient Responsiblity
Consent Form	Patient Responsiblity
MDA Release Form	Patient Responsiblity
Advance Beneficiary Notice	Patient Responsiblity
Skilled Nursing Care and Hospice Confirmation	Patient Responsiblity
Disclosure of Medical Information	Physician
Checklist for Speech Evaluation Report Child Evaluation, Adult Evaluation	Speech Therapist's Responsibilty
Physician's Prescription Certificate of Medical Necessity Prescription for Durable Medical Equipment Must include patient's name, Dr.'s UPIN, Diagnosis, Itemized List of Equipment, signed and dated by treating physician (dated after date of evaluation).

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