Funding Documents

Congratulations on identifying a good candidate for a Lingraphica device! These forms are needed for funding sources such as Medicare and most commercial insurances.

Please note: You must be on a desktop or laptop to download, complete, and sign these forms. You cannot complete these forms on a tablet.

Fax Coversheet

Check off the items as you go to ensure you’ve included everything. You may submit forms electronically.

Speech-Language Pathologist Recommendation Packet

  • Order Form – Please include all information.
  • SGD Evaluation – All fields are required. Omitting a field will result in the form being returned to you for completion.
  • Speech Therapy Notes – Please include speech therapy notes that support the client’s diagnosis, level of severity, and how the device reduces communication, medical, and safety risks.

Personal Interest Form

Recommended but not required

Personal Interest Form (Spanish)

Recommended but not required

Creating a Digital Signature

You can now sign your documents digitally! Digital signatures are safe, secure and legally binding, marked with a tamper-evident seal. Watch the video for instructions to create your signature and sign your documents.

Adobe Reader

Click here to download and install Adobe Reader to view, fill and sign these documents.

Patient Documents

Assignment of Benefits (AOB)

This signed document is required and allows Lingraphica to seek and obtain direct payment from an insurance company/payor for a Lingraphica device and accessories.

Assignment of Benefits - Spanish (AOB)

This signed document is required and allows Lingraphica to seek and obtain direct payment from an insurance company/payor for a Lingraphica device and accessories.

Appointment of Representative (AOR)

This document allows Lingraphica to act as a representative on behalf of the client in the event of a denial from an insurance company/payor.  The client is required to fill out Name of Party, Beneficiary Number, and Section I.  Signature of Patient should be signed under the box Signature of Party Seeking Representation.

Authorization to Release Protected Health Information (ARPHI)

This signed document is required and gives Lingraphica permission to release/use/disclosure of health information as needed for the purpose of obtaining a speech generating device.  Lingraphica does not sell or share patient information with outside parties.

Authorization to Release Protected Health Information - Spanish (ARPHI)

This signed document is required and gives Lingraphica permission to release/use/disclosure of health information as needed for the purpose of obtaining a speech generating device.  Lingraphica does not sell or share patient information with outside parties.

Financial Assistance Application

This signed document gives Lingraphica the necessary information for assessing your financial need. You must speak to a Funding Coordinator before filling out this form.

Contact Your Documentation Specialist

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