Next Step Benefit Check

Next Step Project - QuickTalker Freestyle Benefit Check
Click Here to Access the Project Management Portal
Speech-Language Pathologist Information
First name *
Last name *
Business phone*
Extension
Mobile Phone*
SMS Terms - adds default checkmark

Yes
Email*
School Name*
This Section Is Regarding The Individual For Whom The Device Is Being Requested
Student's first name*
Individual for whom device is being requested.
Student's last name*
Individual for whom device is being requested.
Student's date of birth*
MM/DD/YYYY format
Student's gender assigned at birth*

FemaleMale
Has the student ever had a speech device that was paid for by insurance?*

Yes, to my knowledge, they have a speech device that was paid for by insurance.No, to my knowledge, they have not had a speech device that was paid for by insurance.Unsure. I am unsure if the speech device they are using was paid for by insurance.
Additional information you can provide regarding your student's previous or current device includes what year the speech device was paid for by insurance, what manufacturer supplied the device, why is a new device being requested, and did you recommend the previous device?
Student's address*
Address 1
Address 2
Student's city*
Student's state*
Student's zip code*
Family Contact / Legal Guardian Information
Family contact / legal guardian first name*
Family contact / legal guardian last name*
Family contact / legal guardian email*
This email address is required so we can send additional forms for signature.
Family contact / legal guardian mobile phone*
NOTE: As part of the funding process and to verify coverage, an AbleNet staff member will need to contact the parent or caregiver to obtain the following:

1. All medical insurance information for the student

2. Medical release document signed by the student’s family/caregiver (if under the age of 18)

3. Client/student’s primary doctor’s contact information to obtain a DME order for the QuickTalker Freestyle
Do you have the student's insurance information? If yes, we will confirm coverage within 1-business day.*

YesNo
Primary insurance company name
ID number from card
Provider service phone number from back of insurance card
Secondary insurance company name (if applicable)
ID number from card
Provider service phone number from back of insurance card
Please upload front and back of all health insurance cards including Medicare and Medicaid.

All insurance card copies must be uploaded
Cancelof
As part of the AbleNet Funding Service, the medical benefits team will let you know if your student's insurance requires a trial device. This trial device, if required, is provided free of charge by AbleNet.
Doe the family/legal guardian require language translation?*

YesNo
Language required*
Is this your first time submitting a funding request for a QuickTalker Freestyle to AbleNet?*

YesNo
Have you worked with another company to fund a speech device before?*

YesNoOther
Would you like access to the My AbleNet portal so you can follow the status of this benefit check request online?*
By clicking Submit, you agree to our Privacy Policy & Terms of Use
Please verify that you are human*
Student's date of birth
Zapier Gender
archive - Additional information you would like to provide regarding your student (examples might include foreign language translations support for the family, accessories to support the use of the QuickTalker Freestyle, willingness to start the funding process now or need to wait until later, etc.):
Archive - What AAC solution have you used with this student in therapy sessions, at school or at home?
Archive - How did you hear about AbleNet’s funding service and QuickTalker Freestyle?
Archive - Student's place of residence

HomeGroup homeOther
Should be Empty:

Next Step Project - QuickTalker Freestyle Benefit Check

Speech-Language Pathologist Information

This Section Is Regarding The Individual For Whom The Device Is Being Requested

Family Contact / Legal Guardian Information