Smart Paperwork

Say goodbye to paper, fax, and email. Complete your client’s paperwork in a fraction of the time!

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“The paperwork portal and direct email support/training from staff was much appreciated.”
– SLP who conducted a trial

Easy as 1-2-3

Trial Documentation in Half the Time

With Lingraphica’s Smart Paperwork Portal, you will be able to access all of the documents for each of your clients and submit them in record time.

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Paperwork Questions? We’re Here to Help!

Call us at 888-274-2742 or reach out to your Documentation Specialist directly.

Backup Paper Funding Documents

These forms should only be used as a backup for the Smart Paperwork Portal. If you are having trouble accessing the portal, please reach out to your Documentation Specialist or call us at 888-274-2742.

Please note: You must be on a desktop or laptop to download, complete, and sign these forms. You cannot complete these forms on a tablet.

Fax Coversheet

Check off the items as you go to ensure you’ve included everything. You may submit forms electronically.

Speech-Language Pathologist Recommendation Packet

  • Order Form – Please include all information.
  • SGD Evaluation – All fields are required. Omitting a field will result in the form being returned to you for completion.
  • Speech Therapy Notes – Please include speech therapy notes that support the client’s diagnosis, level of severity, and how the device reduces communication, medical, and safety risks.

Personal Interest Form

Recommended but not required

Personal Interest Form (Spanish)

Recommended but not required

Creating a Digital Signature

Adobe Reader

Click here to download and install Adobe Reader to view, fill and sign these documents.

Patient Documents

Assignment of Benefits (AOB)

This signed document is required and allows Lingraphica to seek and obtain direct payment from an insurance company/payor for a Lingraphica device and accessories.

Assignment of Benefits - Spanish (AOB)

This signed document is required and allows Lingraphica to seek and obtain direct payment from an insurance company/payor for a Lingraphica device and accessories.

Appointment of Representative (AOR)

This document allows Lingraphica to act as a representative on behalf of the client in the event of a denial from an insurance company/payor.  The client is required to fill out Name of Party, Beneficiary Number, and Section I.  Signature of Patient should be signed under the box Signature of Party Seeking Representation.

Authorization to Release Protected Health Information (ARPHI)

This signed document is required and gives Lingraphica permission to release/use/disclosure of health information as needed for the purpose of obtaining a speech generating device.  Lingraphica does not sell or share patient information with outside parties.

Authorization to Release Protected Health Information - Spanish (ARPHI)

This signed document is required and gives Lingraphica permission to release/use/disclosure of health information as needed for the purpose of obtaining a speech generating device.  Lingraphica does not sell or share patient information with outside parties.

Financial Assistance Application

This signed document gives Lingraphica the necessary information for assessing your financial need. You must speak to a Funding Coordinator before filling out this form.

See More Resources for SLPs

SLP Resources