Funding & Insurance
At LC Technologies, we know that navigating the various channels of insurance can be confusing and frustrating. We are here to help!
Please complete the following forms to get started and send by email, fax, or regular mail to our Funding Manager:
- User Insurance Form (PDF File) – please fill this out entirely and attach copies of ALL insurance cards, front and back. Also you can fill this form out by clicking here.
- Authorization for Release of Information Form (PDF File) – please fill in whom LC Technologies is allowed to talk to about the patient. For instance, you may want to list the insurance company, doctor, SLP, and family.
- Financial Responsibility Form (PDF File) – explains the financial responsibility for the Eyegaze Edge device.
The following forms are for your records only:
- Sample Prescription (PDF File) – your doctor may fill out this form or write on his own prescription pad. It is necessary for all items to be listed or described. This can be filled out ahead of time by LC Technologies, the family, or SLP, as long as the physician reviews it and signs.
Please note: As of July 1, 2013,”a physician must document that a physician (or physician assistant, nurse practitioner, or clinical nurse specialist) has met with the patient within 6 months before the written order for the SGD.”
- Sample SLP Report (DOC File) – your speech language pathologist must write a report recommending our device for insurance to cover it. This is a sample that can be filled in and edited.
Speech Generating Devices are covered by Medicare, Medicaid, Tricare, the VA, and most private health insurance companies. LC Technologies participates with most of these insurance companies, including Medicare. We will help you through the insurance process and file the claim on your behalf. To get started, please read below for more information about each form needed. We will contact you and the insurance company and keep you updated of the whole process.