Assignment of Benefits

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Client Information
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Name*
Phone*
Shipping Information
Address*
City*
State*
Zip*
Assignment of Benefits
I choose to receive the speech-generating device through my insurance company, and I authorize Medicare and/or other insurance(s) to furnish payment(s) directly to Lingraphicare America, Inc. (LCA) for its services. I also authorize LCA to release my medical information to any insurance company to determine whether benefits are payable. Should I receive payment directly from the insurance company, I agree to forward the check and Explanation of Benefits (EOB) to LCA within 10 days of receipt. I understand that the check and EOB are due to LCA in order to credit my account. If I fail to provide this information, I understand that I will be held legally responsible for payment in full for all equipment and/or services that have been provided by LCA.
Privacy Policy
I have read and understand the privacy policy of Lingraphicare America, Inc. available at lingraphica.com/privacy-policy.
Communication Policy
I acknowledge Lingraphicare America, Inc. may contact me to coordinate care, provide additional trainings, and to provide coverage reminders and changes.
Ownership of a Speech-Generating Device
Have you ever owned a speech-generating device?*
- Yes
- No
Make*
Model*
Date of Purchase*
MM slash DD slash YYYY
Was the device paid for by your current insurance company?*
- Yes
- No
Client Authorization
I have read and agree to the provisions noted above:
Signature of Client or Authorized Individual*
Date Signed*
MM slash DD slash YYYY
Print Name of Client or Authorized Individual*
Relation to Client*
Other
Reason Client is Unable to Sign*

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Client Information

Please remember to Submit or Save your your work at the bottom of this form or your progress will not be saved!

Shipping Information

Assignment of Benefits

Privacy Policy

Communication Policy

Ownership of a Speech-Generating Device

Client Authorization