STATE MEDICAID FORMS

Medicaid is a Federal-State health insurance program that is jointly-funded to provide assistance for eligible low-income people. Some states have waivers which allow Medicaid coverage for families at higher income levels when they have a child with a disability. The Federal government provides national guidelines and each of the States establishes its own eligibility standards, defines the type, amount, duration, and scope of services, establishes the rate of payment for services, and administers its own program (Centers for Medicare & Medicaid Services, 2002).

Tobii Dynavox is a participating provider with all 50 state Medicaid programs.

Some states require additional forms, which are listed below.

Arkansas
Arkansas Prior Authorization Request Form

California
California Prior Authorization Request Form

Connecticut
Connecticut Prior Authorization Request Form

Florida
Florida Statement of Non-Conflict
Florida School Concurrence

Georgia
NOTE: A copy of the most current Individualized Education Plan (IEP) must be submitted with the funding packet for a student under the age of twenty-one (21) if applicable.

Indiana
Indiana Augmentative Communications System Selection
Indiana Prior Authorization Request Form

Kentucky
Kentucky Certificate of Medical Necessity

Maine
Maine 2014 Durable Medical Equipment Criteria

Maryland
Contact Us or Call 800-344-1778

North Carolina
Contact Us or Call 800-344-1778

North Dakota
North Dakota Prior Authorization Form
North Dakota Certificate of Medical Necessity

Nebraska
Nebraska Prior Authorization Request Form
Nebraska AC Device Selection Report

New Hampshire
New Hampshire AAC Application
New Hampshire AAC Safe Guarding Plan
New Hampshire Trial Summary

Ohio
Ohio Certificate of Medical Necessity-Initial Request
Ohio Certification of Medical Necessity-Repairs

Oklahoma
Oklahoma Prior Authorization Request Form

Oregon
Oregon AAC Selection Report
Oregon EDMS Coversheet
Oregon Prior Authorization Request Form

Pennsylvania
Pennsylvania Outpatient Services Authorization Request

Rhode Island
Rhode Island Certificate of Medical Necessity
Rhode Island Prior Authorization Request Form

South Carolina
South Carolina Certificate of Medical Necessity

Texas
Texas Physician Order Form

Vermont
Vermont Durable Medical Equipment Ownership, Operation, and Maintenance Agreement
Vermont SGD/AAC Prescription for E2510-12
Vermont Speech Language Pathologist Evaluation

Virginia
Virginia Certificate of Medical Necessity

Washington
Washington Speech Language Pathologist Evaluation
Washington Prescription Form