Client Information Form

Please provide as much information as possible in the following fields. A red asterisk (*) to the right of a prompt, indicates that a response is required for that field.

PART A - Eligibility Form

Section 1: Client Information

Male
Female
Unspecified

Please provide at least one of the following methods of contacting you.

Single
Married
Divorced
Widowed
Deaf
Hard of hearing
Hearing
Late deafened
Blind
Low vision
Sighted

Section 2: Insurance Information

You need to be covered by at least one of the following providers to proceed. Please indicate under which one(s) you are covered, and provide all requested information related to that provider.


Yes No
Yes No
Yes No
Yes No
Yes No

Section 3: Primary Care Provider (Family Doctor) / Hospital Information

Yes No

Section 4: Time Availability

8 AM - 12 PM
1 PM - 5 PM
Monday
Tuesday
Wednesday
Thursday
Friday
Text
Videophone
Email
Facebook Messenger
FaceTime

Section 5: Transportation Availability

You must be able to attend doctor (PCP) and speech-language pathologist (SLP) appointments to evaluate your eligibility to receive coverage for a UbiDuo SGD communication device. Please indicate if you are able to use your own transportation to get to these appointments, or if you will need to use alternative transportation.

Yes No

Section 6: Remote Evaluations

Some speech-language pathologists (SLPs) are able to perform evaluations remotely via video conferencing tools such as Zoom or Google Meet. If you have access to a laptop or computer equipped with a webcam, an iPad, or a tablet that can work with these tools, and if you are willing to have your SLP evaluation done remotely, then you may indicate this below.

NOTE:  Videophones, cell phones or other mobile devices that have small screens cannot be used for remote evaluations. Change this option only if you have access to a suitable device and know how to use it to connect to a remote meeting.

PART B - Client Certification

Please read and check the box to the left of each statement:

By checking the checkboxes below and affixing my signature at the end of this form, I indicate my legal agreement with and acceptance of each item.

I verify that all information contained herein is correct and true to the best of my knowledge. I also understand that the information provided will be used by sComm for the purpose of obtaining Medicare covered equipment, and I hereby give permission to sComm for this information to be released as required by the Medicare sources listed.
I understand that I may be able to purchase the equipment that has been prescribed by my doctor. The duration will be according to the manufacturer’s policy.
I understand I am subject to the Terms and Conditions of the purchase.
I will keep (and be on time for) all scheduled appointments with the Primary Care Provider (PCP) / Family Doctor and the Speech Language Pathologist (SLP). If I need to reschedule for a good reason, I am responsible to notify my sComm representative to reschedule the appointments. One PCP appointment is excused, and one SLP appointment is excused.
If I cancel my second PCP and/or SLP appointment(s), I am fully responsible to make a call to reschedule the appointments.
Failure to attend the appointments will result in your status being set to inactive.
I am responsible to pay the co-payment for PCP/SLP fees.
I understand that I am responsible to pay $15.00 for an accessory (1/2 of UbiDuo SGD device).
Please contact your sComm representative if you are planning to add additional health insurance during the approved Medicare process to avoid reversal of your approval. sComm asks you to remain with your current Medicare until the process is completed and you have received your UbiDuo SGD.

PART C - Health Insurance Portability and Accountability Act (HIPAA)

HIPAA Privacy Authorization Form Authorization for Use or Disclosure of Protected Health Information (Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)

  1. Authorization: I authorize
    to use and disclose the protected health information described below to Communication Advisors/Staff of sComm.
  2. Effective period: This authorization for release of information covers the period of healthcare from to (period of 24 months from current date).
  3. I authorize my primary care provider (PCP), speech-language pathologist (SLP), and insurance provider to release my protected health information to sComm for the purpose of obtaining a referral for evaluation by a speech-language pathologist for durable medical equipment (DME) for communication, for obtaining a prescription for the recommended DME, and for seeking coverage for the purchase of the recommended DME.
  4. I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.
  5. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.
By checking the checkbox to the left and affixing my signature below, I indicate my legal agreement for my protected health information to be disclosed to sComm and used as specified above.

Signature:*

Note that your full signature is required. Your initials or a dot are not acceptable.

PART D - Cancellation Policy

sComm has instituted a Doctor and SLP Appointment Cancellation Policy. A cancellation made with less than a 24-hour notice significantly limits our ability to make the appointment available for another patient in need. We understand that there are times when you must miss an appointment due to emergencies, however, when you do not call to cancel a doctor and/or SLP appointment, you may be preventing another patient from receiving much needed services.

To remain consistent with our mission, we have instituted the following policy:

  1. Provide our office with a 48-hour notice in the event that you need to reschedule your doctor appointment and a 72-hour notice if you need to reschedule your SLP appointment.
  2. A "No-Show," "No-Call," or missed doctor and/or SLP appointment, without proper notification, will result in a charge of a $40.00 fee. This fee will not be covered by your insurance provider.
  3. If you are more than 15 minutes late for your doctor and/or SLP appointment, the appointment may be cancelled and rescheduled.
  4. Repeated missed or cancelled doctor and/or SLP appointments may result in termination of service.

If you have any questions regarding this policy, please let your sComm representative know. We will be glad to clarify any questions you may have. A copy of this policy is provided to you. Please indicate your acknowledgement below.


By checking the checkbox to the left and affixing my signature at the end of this form, I indicate that I have read and understand the Doctor and SLP Appointment Cancellation Policy and I acknowledge its terms. I also understand and agree that such terms may be amended from time to time with approval.

PART E - Disclaimer of Commercial Insurance Prior Authorization

By checking the checkbox to the left, I indicate my understanding that sComm, Inc. is an out of network provider with most commercial insurance companies, and this may include my insurance. I am authorizing sComm, Inc. to proceed through the prior authorization process on my behalf. I also understand that sComm, Inc. will follow through all necessary guidelines provided by my insurance to provide the best possible outcome in receiving an approval of payment for the UbiDuo SGD. This does not guarantee that the insurance will cover the cost of the UbiDuo SGD, and if my insurance does not cover the cost, the UbiDuo SGD will not be shipped to me. I will have the opportunity, at that time, to pay for the unit out of pocket if I choose to proceed.

PART F - Final Acceptance and Signature

If you are completing and signing this form for someone else (i.e. you are the patient's parent, guardian, personal representative, or power of attorney [POA]), then check the box to the left.

Do not check the box if you are completing this form for yourself.


By signing below, I am indicating that all responses entered in the form above are true and complete to the best of my knowledge, that I have read and understand the terms and requirements provided on this page, and that I agree to be bound by them.

Signature:*

Note that your full signature is required. Your initials or a dot are not acceptable.

Please review your responses above to ensure that all required information has been provided and there are no errors that were flagged by the system. When ready, click the blue Submit button below to proceed to the next page where you will upload photos of your identification and insurance cards.