AAC Funding - Forms

Funding Forms

Quickly and accurately completing all of the necessary paperwork is the key to a successful submission to your insurance company.

Once you log into the Funding Application Portal, all necessary paperwork will be provided to the AAC team. This web page contains addition information and forms you may need to fill out to complete an application. It is very important that all necessary team members have an account to the Funding Application Portal, so they can contribute to the completion of the application.

Supporting Documents

Below are links to our Client Bill of Rights, Supplier Standards, and Privacy Practices for your reference.

State Documents

No documents available for this state.

Medicare Documents

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 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.

Filing Offline?

Please complete and include the necessary Equipment Selection Sheets(s) with your submission.

Non-funded Device Rental Contracts

If you need to rent a device from us that does not involve your insurance, please use the following forms.