Patient Agreement and Consent Form

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I hereby authorize the release/use/disclosure of my health information as it relates to treatment, prognosis and diagnosis, and billing information. Records that may be released include: all medical records pertaining to my medical history.

These records may be released to:
Lingraphicare America, Inc.
700 Alexander Park, Ste 101
Princeton, NJ 08540

I understand that signing this authorization is voluntary. I understand that any and all records, whether written, oral, or in electronic format, are confidential and cannot be disclosed without my prior written authorization, except as otherwise required by law (e.g., Medicare Law). I understand that a photocopy of this authorization that is delivered in person, by mail, e-mail, or fax is as valid as the original. I understand that my treatment, payment, enrollment or eligibility for benefits is not conditioned on whether this authorization is signed. I understand that any information disclosed per the Authorization may be re-disclosed by a recipient and is no longer protected by federal or state health privacy laws. I understand that I have the right to revoke the authorization in writing at any time by presenting the revocation to a Lingraphica Employee. I understand that this authorization expires one year from the date it is signed.

I appoint the Lingraphicare America, Inc. (LCA) authorized representative listed below to act as my representative in connection with my claim or asserted right under Title XVIII of the Social Security Act (the “Act”) and related provisions of Title XI of the Act. I authorize this company to make any request; to present or to elicit evidence; to obtain appeals information; and to receive any notice in connection with my claim, appeal, grievance or request wholly in my stead. I understand that personal medical information related to my request may be disclosed to LCA.

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 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.

I have read and understand the privacy policy of Lingraphicare America, Inc. available at lingraphica.com/privacy-policy.

I acknowledge Lingraphicare America, Inc. may contact me to coordinate care, provide additional training, and to provide coverage reminders and changes.

The person signing this consent form may receive a copy upon request. The person signing this attests that they are legally allowed to sign on behalf of the patient if they are not able to do so. By signing this, I agree to all the terms and conditions stated above.