Internal Patient Benefit Check

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Internal Patient Benefit Check

Who is completing this intake?*
Sales Channel*
Patient Information
First Name*
As it appears on insurance card
Last Name*
As it appears on insurance card
Date of Birth*
Gender*
Pronoun
- She/Her
- He/Him
- They/Them
Phone Number
Type of Phone*
Alternative Phone Number
Email*
Which language do you prefer to use when communicating with the Lingraphica team?*
- English
- Spanish
- Other
Please confirm your monolingual or bilingual needs*
How would you like us to contact the patient?
By selecting "Text," you agree to receive SMS messages from Lingraphica. If you do not wish to receive SMS messages from Lingraphica, please choose a different contact method.
Where do you currently reside?*
Please indicate where you currently reside.*
Name and/or Type of Facility
Approximate Discharge Date
Where will you reside after you are discharged?*
Street Address*
Street Address 2
Country*
City*
State*
State/Province/Region*
Zip Code*
Medical Information
Medical Diagnosis*
Please indicate your diagnosis
Speech Diagnosis
- Aphasia
- Apraxia
- Dysarthria
- Other
Date of Onset
Is the medical diagnosis the result of an accident?
- Yes
- No
Date of Accident
Is the insurance covering treatment for the medical diagnosis a liability insurance?
- Yes
- No
Type of liability insurance (ex. Auto / Workers Compensation)
Are you seeing a speech therapist?*
- Yes
- No
What is your speech therapist's first and last name?*
Phone number for your speech therapist*
Email address for your speech therapist
When did you last see your speech therapist?
Did the SLP prompt them to reach out to Lingraphica?*
What is your physician's first and last name?
Phone number for your physician
Are you receiving hospice care?*
- Yes
- No
Primary Insurance Information
Would you like to upload a photo or scan of your patient's primary insurance card?*
- Yes
- No
Primary Insurance Card*
Drop files here or

Max. file size: 40 MB.
You can upload photos or scans of your insurance card. Please upload the front AND back of your insurance card.
What is your primary insurance?*
Member ID/Policy Number*
Group Number
Insurance Provider Hotline Phone Number
What is your relationship to the policyholder?*
Name of policyholder*
Policyholder's date of birth*
Do you have secondary/supplemental insurance?*
- Yes
- No
Secondary Insurance Information
Would you like to upload a photo or scan of your patient's secondary insurance card?*
- Yes
- No
Secondary Insurance Card*
Drop files here or

Max. file size: 40 MB.
You can upload photos or scans of your insurance card. Please upload the front AND back of your insurance card.
What is your secondary/supplemental insurance?*
Member ID/Policy Number*
Group Number
Insurance Provider Hotline Phone Number
What is your relationship to the policyholder?*
Name of policyholder*
Policyholder's date of birth*
Financial Information
This information will be used to provide you with the more accurate any potential out-of-pocket costs. Please be as accurate as possible, however estimates are acceptable. These questions are optional but highly recommended.
Family/Household Size
Total Household Monthly Income
Total Household Monthly Expenditure
Please include all household expenses such as mortgage/rent, utilities, medical expenses, etc.
I hereby acknowledge that the information given herein is true and correct.
- ACKNOWLEDGED
Device Information
Have you ever owned a communication device?*
- Yes
- No
When did you purchase your communication device?
Did your current insurance company pay for your communication device?
- Yes
- No
Caregiver/Emergency Contact Information (if applicable)
Name of spouse, caregiver, or support person
Phone number of spouse, caregiver, or support person
Email of spouse, caregiver, or support person
What is their relationship to you?
- Spouse
- Parent
- Child
Is the caregiver the patient's legal guardian or Power of Attorney?
- Yes
- No
- I don't know
What language does the primary caregiver/communication partner prefer to use when communicating with Lingraphica?
- English
- Spanish
- Other
May we reach out to the caregiver/communication partner?*
- Yes
- No
- Not yet
How would you like us to contact them?
How did you hear about us?*
Please explain how you heard about Lingraphica.*
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Internal Patient Benefit Check

Patient Information

Medical Information

Primary Insurance Information

Secondary Insurance Information

Financial Information

Device Information

Caregiver/Emergency Contact Information (if applicable)