Client Information Form

Please fill out the following form to begin your UbiDuo application.

Section 1: Client Information

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Select Current Marital Status

Section 2: Insurance Information

Part
Medicaid Insurance
Medicare Supplement
Medicare Advantage
Private Insurance

Section 3: Primary Care Provider (Family Doctor)

Do you have a family doctor (PCP)?

Section 4: Time Availability

Appointment Slot
Day Availability
Contact Me Via

Section 5: Client Certification

Please read and check the box next to each statement

Signature(s) of person(s) completing this form:

1. Authorization

 

I authorize

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 for a period of six (6) months from the current date.

from:

to:

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.

Signature

*Must be signed by legal name or POA

Section 7: 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.

Signature of Patient or Personal Representative

*Must be signed by legal name or POA

Section 6: 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)

Products
Deaf Communication Devices
(without speech, for greater privacy)
Company

Careers

Contact

Toll Free: 866.505.7008

Local: 816.350.7008

Video Phone: 816.527.9079

Fax: 816.737.1790

Speech Generating Devices (SGD)
(deaf communication devices with speech)
Medicare Approved!
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6238 Hadley Street,
Raytown, MO 64133