Medical Release & Assignments of Benefits
I authorize the release of any medical or other information necessary for determining benefits payable for equipment and processing claims by my insurance carrier, accrediting agencies, and any other school, medical or insurance entities. If requested, a copy of this authorization will be sent to my insurance company or other medical insurance entities.
I authorize payment of insurance benefits to AbleNet, Inc. for any equipment provided to me. If I fail to provide all insurance information, including Medicare and Medicaid, I also understand that I could be held legally responsible for payment in full for all equipment provided. I also understand that I am financially responsible for any charges not covered by my healthcare benefits. NOTE: You will be notified, in advance, if there are any applicable charges.
By signing this document, I am authorizing the medical release of information and understand I have received a financial beneficiary notice. I understand and acknowledge downloading, for my records, AbleNet's warranty and return policy, patient rights and responsibilities, supplier standards, client privacy information, product manual, and complaint policy.
Coordinating Information and Communication
In processing your request for a QuickTalker Freestyle speech device, AbleNet, Inc. will communicate with you, your medical providers, school staff, and/or other parties to coordinate information required by your insurance company. AbleNet will use email, fax, and SMS (text message) to coordinate the communication. In some cases, the communication could include protected health information (PHI). We carefully manage all communications and do our best to ensure your information is protected throughout the funding process.
By signing this document, I am authorizing AbleNet to use email, fax, and SMS messages that may contain PHI to process my QuickTalker Freestyle request.
Agency Agreement to Configure Your QuickTalker Freestyle
AbleNet’s QuickTalker Freestyle device uses a speech software application available through the Apple App Store. The speech software application selected by the speech-language pathologist has an End User License Agreement (EULA) that requires you to provide AbleNet permission to install it onto your QuickTalker Freestyle device on your behalf.
By signing, I hereby confirm that I will have purchased the device (which is paid for by my health insurance) on which the selected communication app will be installed. Once approved by my health insurance, I realize I am the owner of the device. I represent and warrant that I am authorized to decide, with the recommendation of the speech-language pathologist, the communication app installed on the device. Once installed, I agree to the license agreement and to sign on the user’s behalf.
I agree to appoint AbleNet as my agent to configure the QuickTalker Freestyle device. I accept the terms of, and agree to be bound by, the EULA for the speech application selected.
NOTE: A copy of this medical release document will be sent to the email address you provide below as well as copies of AbleNet’s return policy, patient rights and responsibilities, the supplier standards, and client privacy information.