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:

• Completed Client Profile
  

• 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

Mail Forms to...
   Advanced Multimedia Devices, Inc.
   Funding Department
   200 Frank Road
   Hicksville, NY 11801

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