Hearit Forms and Information for Funding and Reimbursement
Although Hearit Auditory Tools are reasonably priced, clinicians often face limited budgets. However, if the clinician performs an evaluation accessing the student's difficulty and how Hearit can benefit, there are various funding options.
The information and forms below will help you to acquire Medicaid funding for Hearit Auditory Tools. To read about various funding options and procedures, we recommend you download and review our Detailed Funding Guide for all States by clicking here . For some of these forms you will need to have Adobe Acrobat Reader. If you need to download it, please click on the yellow icon below:
The following Medicaid information and forms are available here. Click the map below to go directly to your State:
Forms for All States
1 - Detailed Funding Guide for all States- Click
2 - Sources of Funding - All States
3 - General Release of Information Form - All States- click
4 - Funding Questionnairre (used for all states except Texas,Arizona, Colorado) - click
Forms for Arizona Only
Provider ID #548620
1 - Arizona AHCCCS Prior Authorization Request Form - click
2 - Arizona Funding Checklist - click
3 - Arizona Release of Information - click
Forms for Colorado Only
Provider ID #48620050
1 - Colorado Funding Checklist - click
2 - Colorado Funding Questionairre - click
3 - Colorado Prior Authorization Request Form - click
Forms for Indiana Only
Provider ID #200276180
1 - Indiana Prior Authorization Request Form - click
2 - General Release of Information Form - All States- click
3 - Funding Questionnairre (used for all states except Texas,Arizona, Colorado) - click
Forms for Kansas Only
Provider ID #7587220001
1 - Kansas Prior Authorization Request Form - click
2 - General Release of Information Form - All States- click
3 - Funding Questionnairre (used for all states except Texas,Arizona, Colorado) - click
Forms for Kentucky Only
Provider ID #90002650
1 - Kentucky Prior Authorization Request Form - click
2 - General Release of Information Form - All States- click
3 - Funding Questionnairre (used for all states except Texas,Arizona, Colorado) - click
Forms for Maryland Only
Provider ID #097003400
1 - Maryland Prior Authorization Request Form - click
2 - General Release of Information Form - All States- click
3 - Funding Questionnairre (used for all states except Texas,Arizona, Colorado) - click
Forms for Mississippi Only
Provider ID #00440807
1 - Mississippi Authorization Request - Durable Medical Equipment (DME) - click
2 - General Release of Information Form - All States- click
3 - Funding Questionnairre (used for all states except Texas,Arizona, Colorado) - click
Forms for Montana Only
Provider ID #5604492
1 - Montana Prior Authorization Request Form (Augmentative Communication ) - click
2 - Montana Prior Authorization Request Form (Durable Medical Equipment - DME) - click
3 - General Release of Information Form - All States- click
4 - Funding Questionnairre (used for all states except Texas,Arizona, Colorado) - click
Forms for Ohio Only
Provider ID #2211770
1 - Ohio Prior Authorization Request Form - click
2 - General Release of Information Form - All States- click
3 - Funding Questionnairre (used for all states except Texas,Arizona, Colorado) - click
Forms for Pennsylvania Only
Provider ID #01833411
1 - Pennsylvania Prior Authorization Request Form - click
2 - General Release of Information Form - All States- click
3 - Funding Questionnairre (used for all states except Texas,Arizona, Colorado) - click
Forms for Texas Only
Provider ID DME00U226
1 - Texas Funding Check List and Questionnaire - click
2 - Texas THSteps - CCP Prior Authorization Request Form - click
3 - General Release of Information Form - All States- click
Forms for Wyoming Only
Provider ID #115900300
1 - Wyoming Prior Authorization Request Form - click
2 - General Release of Information Form - All States- click
3 - Funding Questionnairre (used for all states except Texas,Arizona, Colorado) - click
We are certified Durable Medical Equipment (DME) providers for Medicaid in the following States:
Idaho (#805932400 and #80593240),Illinois (#860750903001), Indiana, Kansas, Louisiana (#097003400), Maryland, Minnesota (#5524920-00), Mississippi, Montana, Ohio, Pennsylvania, Texas, Washington(#9050519),and Wyoming