The following information is needed to Purchase or Rent a Speech Generating Device:

• Client Information Form
  
• Copy of recipient's Medicare card
  
• Certificate of Medical Necessity (CMN) completed by your physician
  
• Complete speech/language evaluation performed by a licensed speech pathologist
  
• Any additional letters of support
  
• Assignment of Benefit Form
  
• Medicare Advance Beneficiary Notice (ABN) (if applicable)
  
• Insurance explanation of benefits (if applicable)
  
• Signed trial/evaluation contract (if applicable)
  
• I have been provided with PRC's privacy policy

The following information is needed to Repair a Speech Generating Device:

• Copy of recipient's Medicare card
  
• Certificate of Medical Necessity (CMN) from your physician
  
• Letter of recommendation from your speech pathologist
• Assignment of Benefit Form

To expedite your request in a timely manner, please forward documentation to PRC using one of the below methods:

Email: This e-mail address is being protected from spam bots, you need JavaScript enabled to view it or Fax: 330-262-5783, Attn: Funding Dept

or Mail to:
Prentke Romich Company
Attn: Funding Dept
1022 Heyl Rd
Wooster OH 44691