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Required Funding Documents (Return the Completed Documents to ACCI)

Required Funding Documents (Return the Completed Documents to ACCI)

 

Speech Language AAC Evaluation    (Completed by the Speech Language Pathologist before Script is written).

 

Client Information & Assignment of Benefits Form

  • If insurance, then signed by primary insurance policy holder
  • If Medicaid, then signed by client; if client unable to sign or if a minor, then needs to be signed by witness

Certificate of Medical Necessity (CMN)

  • Physician will need to sign the form.  List specific devices and all accessories being prescribed, including diagnosis, length of need and physician's NPI number.
  • If eligible for Medicaid in addition to Insurance, physician may need to use a state specific Medicaid CMN

Copy of Recipient's Medicaid/Insurance Card

  • Legible copy of the front and back of cards
 

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