Good Faith Financial Assessment

Error

There was an issue retrieving information. Please refresh your page and try again. If you've made several attempts without success, please contact your Documentation Specialist for assistance.

Please complete the following information completely and to the best of your ability.

Patient Name(Required)

Form completed by (Name)(Required)

Relationship(Required)

Shipping Address for Device

Street Address 1(Required)

Street Address 2

City(Required)

Zip / Postal Code(Required)

State / Province / Region(Required)

Country(Required)

Caregiver Information

Name

Phone

Requested Device(Required)

TouchTalk (10" Tablet)

TouchTalk Plus LTE (12.4" Tablet)

TouchTalk Plus Wi-Fi Only (12.4" Tablet)

MiniTalk (8" Tablet)

Requested Accessories

Mouse (Wireless)

Mouse (Wired)

Joystick

Mount (please contact your Clinical Consultant for details)

Rugged Case

Custom Stylus (please contact your Clinical Consultant for details and specify),

Other (please contact your Clinical Consultant for details and specify),

Financial Information

Please provide as much information as possible. The financial information provided is used to calculate a discount based on our sliding scale.

Family/Household Size(Required)

Total Household Monthly Income(Required)

Total Household Monthly Expenditures(Required)

I hereby acknowledge that the information given herein is true and correct. I authorize Lingraphica to verify any information contained in this document for the sole purpose of assessing financial need.

Printed Name (Patient or Responsible Party)(Required)

Signature(Required)

Date(Required)