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