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Lingraphica Benefits Site

Internal Patient Benefit Check
Internal Caregiver Benefit Check
Internal Professional Benefit Check

Internal Patient Benefit Check
Internal Caregiver Benefit Check
Internal Professional Benefit Check

Internal Other Professional Benefit Check

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Internal Other Professional Benefit Check

Clinician Information
I am a/an*
First Name*
Last Name*
Email*
Enter Email Confirm Email
What language do you prefer to speak when communicating with Lingraphica?*
- English
- Spanish
- Other
Do you use your cell phone, work phone, or both?
- Cell Only
- Work Only
- Both
Mobile Phone Number*
Work Phone Number*
Extension
Alternate Phone Number
How would you like us to contact you?*
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.
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*
Alternative Phone Number
Email
Which language does the patient prefer to use when communicating with the Lingraphica team?*
- English
- Spanish
- Other
Please describe your patient’s monolingualism or bilingualism*
Where does the patient currently reside?*
Please indicate where they currently reside.*
Name of facility
Where will the patient reside after discharge?
Anticipated discharge date
Street Address*
Street Address 2
Country*
City*
State*
State/Province/Region*
Zip Code*
Medical Information
Medical Diagnosis*
Please indicate their 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 your medical care being covered by Workers' Compensation, auto insurance, malpractice insurance or another form of liability coverage?
- Yes
- No
Type of liability insurance (ex. Auto / Workers Compensation)
Are they seeing a speech therapist?*
- Yes
- No
Are they willing to run this device trial?
- Yes
- No
What is their speech therapist's first and last name?*
Phone number for their speech therapist*
Email address for their speech therapist
What is their physician's first and last name?*
Phone number for their physician
Primary Insurance Information
What is their primary insurance?*
Member ID/Policy Number*
Group Number
Insurance Provider Hotline Phone Number
What is their relationship to the policyholder?*
Name of policyholder*
Policyholder's date of birth*
Do you have secondary/supplemental insurance?*
If the client has secondary insurance, please include this information as it helps us provide the most accurate estimate of coverage.
- Yes
- No
Secondary Insurance Information
What is their secondary/supplemental insurance?*
Member ID/Policy Number*
Group Number
Insurance Provider Hotline Phone Number
What is their 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
Has the patient ever owned a communication device?*
- Yes
- No
When did they purchase their communication device?
Did their current insurance company pay for the communication device?
- Yes
- No
Caregiver/Emergency Contact Information
First Name*
Last Name*
Phone Number*
Email*
What is their relationship to the patient?
- 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
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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