1.  CLIENT

The client is the person who will be receiving the equipment or services.

Client Name (Last, First, MI) 

Status:  Married    Single    Other    Employed    Full-Time Student    Part-Time Student

Sex:      Male    Female                                               Social Security Number:

Currently own a communication device? Yes No   Make/Model:   Date of Purchase:

Current place of residence:  Home   Skilled Nursing Facility   Nursing Facility   Custodial Facility (Assisted Living)

 (check all that apply)         Intermediate Care Facility/Mentally Retarded Facility    In Hospice Program

Name of Facility:   Address:  

State:                   Zip:        County: 

Home Phone:     Work Phone:      Fax:

                     Area Code                                                                    Area Code                                         Area Code

2.  CONTACT/CLIENT ADVOCATE

The contact person is the person who is assisting the client, or is the emergency contact

Name: 

Relationship to Client:  Spouse    Parent    Legal Guardian    Other (please specify)

Address: 

City:      State:      Zip: 

Phone:    Alternate Phone:     Fax:

3.  SPEECH LANGUAGE PATHOLOGIST

The SLP is the clinician that performed the evaluation of the client and provided the written report

Name: 

Address:      E-mail: 

City:      State:      Zip: 

Phone:      Alternate Phone:      Fax: 

ASHA Number:                          State License Number: 

4.  TREATING PHYSICIAN

The treating physician is the medical doctor who has prescribed the requested equipment

Name:      UPIN (Universal Personal ID Number): 

Address: 

City:      State:      Zip: 

Work Phone:     Alternate Phone:    Fax: 

Medicaid Provider Number:                  State License Number: 

5.  DIAGNOSIS

Client condition which requires requested equipment or services

Primary Diagnosis:      Diagnosis Code (ICD-9):      Date of onset: 

Secondary Diagnosis:      Diagnosis Code (ICD-9):      Date of onset: 

Is Diagnosis a result of an accident?  Yes    No

If yes:  Date of accident?     Type of Accident?    Employment  Auto  Other  If Auto: Place (State) 

6.  PRIMARY INSURANCE

Type:  Medicare   Medicaid/Medical Assistance  CHAMPUS/Military Coverage  Private/Group  HMO

Name of Insurance:                       ID Number: 

Contact Name:    Contact Phone:     Contact Fax: 

Billing Address:        State:         Zip: 

Policy Holder/Insured

Name:    Phone:    Fax: 

Address:      State:      Zip: 

Name of Employer:   Employer Address:     State:     Zip: 

Policy Number:     Group Number:     Social Security Number: 

Relationship to Client:  Spouse   Parent     Legal Guardian   Other                        Date of Birth: 

7.  SECONDARY INSURANCE

If the Secondary Insurance is Medicare or Medicaid, just fill in the ID Number below and proceed to Equipment

Type:  Medicare   Medicaid/Medical Assistance  CHAMPUS/Military Coverage  Private/Group  HMO

Name of Insurance:                       ID Number: 

Contact Name:    Contact Phone:     Contact Fax: 

Billing Address:        State:         Zip: 

Name:    Phone:    Fax: 

Address:      State:      Zip: 

Name of Employer:   Employer Address:     State:     Zip: 

Policy Number:     Group Number:     Social Security Number: 

Relationship to Client:  Spouse   Parent     Legal Guardian   Other                        Date of Birth: 

8.  EQUIPMENT RECOMMENDATION

Complete list of all equipment, accessories, and parts requested

                                                                                                           Rental         OR        Purchase

9.  SHIPPING INFORMATION

Phone number is required.  Medicare funded devices must ship direct to client.  We cannot ship to a Post Office Box.

Name:       Organization: 

Address:   

City:     State:     Zip:     Phone: 

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