Augmentative Communication Consultants, Inc.

                                                       

 

 

 

Skilled Nursing Care and Hospice Confirmation

Beneficiary Name: (print):

 

HIC#:

Medicare does not pay for Speech Generating Devices (SGD) and accessories if the individual is receiving any of the above care either at home or in a facility at the time of the delivery of the SGD.   Initials

 

If Augmentative Communication Consultants, Inc. is not informed that the individual is receiving skilled nursing care or hospice benefits at the time of the delivery of the SGD and accessories, Medicare will deny the claim as Patient Responsibility.  At that time, the individual and their family would be financially responsible for the Speech Generating Device and any accessories.

 

By signing below the client/client advocate has read and understood the statement above.

 

Signature:      Date: 

 

Augmentative Communication Consultants, Inc.

P. O. Box 731

Moon Township, PA  15108

                           

Telephone:  412 264-6121

Fax:                  412 269-0923

E-mail:              acci1@earthlink.net