Client Information Form

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☐ PART A - Eligibility Form
Section 1: Client Information
Name of Representative
Name
First Last
Date Of Birth*
Social Security #*
Home Address*
Street Address City State ZIP Code
Video Phone #
Phone for text
Email
Are you*
- Single
- Married
- Widow
- Divorced

☐ PART B - Client Certification
Please read and check next to each statement:
*
I verify that all information contained herein is correct and true to the best of my knowledge. I also understand that the information provided be used by sComm for the purpose of obtaining Medicare covered equipment and hereby is giving 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.
Signature(s) of person(s) completing this form:*
Name & Relationship to Client
Date
Date Format: MM slash DD slash YYYY

☐ PART C - 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____________________________________ (name of doctor, hospital or Speech Language Pathologist), 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 12 months from current date).
3. I authorize sComm to discuss and receive my information for purposes of a referral for evaluation by a Speech Language Pathologist for Durable Medical Equipment for Communication. 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 obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.
5. I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization.
6. 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.
Name of patient
First Last
Signature*
If Personal Representative: His or Her relationship to patient
Date
Date Format: MM slash DD slash YYYY
*Must be signed by legal name or POA
☐ PART D – Patient Agreement

I, _________________________________________ understand and voluntarily agree that:

I will keep (and be on time for) all scheduled appointments with the Primary Care Provider PCP (Family Doctor), and Speech Language Pathologist SLP. If I need to reschedule for a good reason, I am responsible to notify Communication Access Advisor to reschedule the appointments. One PCP appointment is excused and one SLP appointment is excused.
If I cancel 2nd PCP and/or SLP appointment(s), I am fully responsible to make a call to reschedule the appointments
Name of patient or Personal Representative
First Last
Signature of patient or Personal Representative*
If Personal Representative: His or Her relationship to patient
Date
Date Format: MM slash DD slash YYYY
*Must be signed by legal name or POA
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