Patient Agreement and Consent Form

Signing this agreement does not obligate you to purchase a device, and you may end the process at any time. However, completing this form is required to obtain a permanent Lingraphica device, and early submission is strongly encouraged to avoid delays.

Why we ask for this information:
Lingraphica collects limited medical information to support the process of obtaining and billing for a speech-generating device (SGD). This form allows your healthcare providers to share those records with us and authorizes us to share them only with those involved in securing your insurance coverage. Lingraphica never sells, rents, or shares your information for marketing or any purpose unrelated to your care.

Patient Name(Required)

Date of Birth(Required)

Address(Required)

City(Required)

State(Required)

Zip(Required)

This should be the patient’s current address. It does not need to match the insurance card. It will not be used for shipping purposes.

Phone(Required)

Other Phone

Medicare Beneficiary or Plan ID Number(Required)

If the patient does not have Medicare, please provide the plan number listed on their insurance card.

Authorization to Release Protected Health Information

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 need for a speech generating device. 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, unless I revoke it sooner.

Appointment of Representative
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.

DO NOT WRITE IN BOX – For Lingraphica personnel use only
I, ___________________________, hereby accept the above appointment and waive my right to charge and collect a fee for representing ___________________________ before the Secretary of HHS.
This document was received on ___________________________ by ___________________________
Lingraphica Authorized Representative Signature: ___________________________

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 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 training, and to provide coverage reminders and changes.

Additional Terms and Conditions
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.

Authorized Signature(Required)

SIGNATURE OF INDIVIDUAL COMPLETING THE FORM

This form will be signed as the date of submission.

Hidden

Date Signed

Printed Name(Required)

NAME OF INDIVIDUAL COMPLETING THE FORM

Relation to Patient(Required)

Authorized Representative Phone Number (if different from patient)

Reason Patient Unable to Sign(Required)

Other (Please Specify):(Required)

Statement of Nondiscrimination and Language Services
Lingraphica follows Federal civil rights laws and does not discriminate, exclude people, or treat them differently because of race, color, national origin, age, disability, sex (including pregnancy, sexual orientation, and gender identity), or religious beliefs.
ATTENTION: If you require assistance to communicate, language assistance services from Lingraphica are available to you, free of charge. Call 1-866-540-1651