FUNDING PACKET INFO.
Funding Checklist & Required Supporting
Documentation
Please coordinate with your Speech Pathologist, Doctor, and Social
Worker to ensure the following items are completed and returned to
AMDi to initiate the funding process for a repair or purchase of an
AMDi product:
-
Copies of BOTH sides of Medicare, Medicaid, and/or all Private Insurance cards and attach copies to this form.
-
A) For Medicare Recipients
- AMDi Release of Information /Assignment of Benefits Form
- Speech/Language Pathologist's AAC Evaluation Report
- Doctor's Original Letter of Medical Necessity specifying the equipment requested listing each item separately giving specific reason for medical justification. NO FAXED COPIES ARE PERMITTED
-
B) For Medicaid Recipients
- Speech/Language Pathologist's AAC Evaluation Report
- Doctor's Prescription specifying the equipment requested listing each item separately. (NYS Form DSS-3615 for New York Residents serves as the Doctor's Prescription) NO FAXED COPIES ARE PERMITTED
- Your State's Doctor's Prior Authorization/Prior Approval Form, if applicable (NYS From DSS-3615 for New York Residents) NO FAXED COPIES ARE PERMITTED
-
C) For Private Insurance Recipients
- AMDi Release of Information /Assignment of Benefits Form
- Speech/Language Pathologist's AAC Evaluation Report
- Doctor's
Original Letter of Medical Necessity specifying the equipment
requested listing each item separately giving specific reason
for medical justification. NO
FAXED COPIES ARE PERMITTED
-
D) For Clients who have ALL Funding Sources
- Send required Documentation outlined in item "C" with your State's Doctor' Prior Authorization/Prior Approval Form (NYS Form DSS-3615 for New York Residents) NO FAXED COPIES ARE PERMITTED