External Caregiver Benefit Check

Lingraphica Operations Requests

Let's Check Your Eligibility

Thank you for considering a Lingraphica communication device, also known as a speech-generating device. To begin a free, no-obligation device trial please complete the entire form below. Please note, it is very important that you fill in all required fields. This information will help our team process your request. If you have any questions, please call our team at 866-570-8775.

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Caregiver/Emergency Contact Information
First Name*
Last Name*
Phone Number*
Email*

Patient Information
First Name*
As it appears on insurance card
Last Name*
As it appears on insurance card
Date of Birth*
Phone Number*
Email
Would you like to give us your insurance information now?*
This will allow us to call you back with more information about what a device will cost you.
- Yes
- No, I will provide it when you call me

Primary Insurance Information
What is their primary insurance?
Member ID/Policy Number
What is their relationship to the policyholder?
Name of policyholder
If different than patient's name
Policyholder's date of birth
If different than patient's date of birth
Do you have secondary/supplemental insurance?
- Yes
- No

Secondary Insurance Information
What is their secondary/supplemental insurance?
Member ID/Policy Number
What is their relationship to the policyholder?
Name of policyholder
If different than patient name
Policyholder's date of birth
If different than patient's date of birth

Before You Finish...
What day(s) are best to contact you?*
- Monday Mornings
- Tuesday Mornings
- Wednesday Mornings
- Thursday Mornings
- Friday Mornings
- Monday Afternoons
- Tuesday Afternoons
- Wednesday Afternoons
- Thursday Afternoons
- Friday Afternoons
Who should we contact?*
- Caregiver
- Patient
How did you hear about us?*
Please explain how you heard about Lingraphica.*
Is there anything you would like Lingraphica to know about your schedule, communication preferences, etc.?

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Caregiver/Emergency Contact Information

Patient Information

Primary Insurance Information

Secondary Insurance Information

Before You Finish...

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