The Tobii Dynavox funding packet has been designed to guide you through the funding process. The packet contains documents that must be completed and submitted.
The required forms listed below and included in the Funding Packet download MUST BE completed and sent to your Tobii Dynavox Funding Coordinator (firstname.lastname@example.org):
- Funding Packet Checklist (For reference only)
- Client Information Form (CIF)
- Lifetime Release & Assignment of Benefits Form – Complete, Sign, and Date
- Physician’s Prescription – Listing the recommended equipment, diagnosis and date. (Not required for Trial)
NOTE: Physician’s personal prescription/order can be used in lieu of this form.
- Trial Agreement – Completed and signed (Not required for Purchase)
Additional Required Documents
These additional documents are also required, but not provided in the download packet above. These items MUST BE included and sent with completed Funding Packet forms:
- SLP Evaluation Form by Speech Pathologist following Medicare or Medicaid protocol (SLP to provide or Visit www.tobiidynavoxfunding.com to complete online)
- Equipment Quote (Contact your Local Consultant for information)
- Clear, legible copies of Insurance, Medicaid and/or Medicare cards (Front and Back)
- State Medicaid forms (If applicable) View Your State Medicaid Forms
- Medicare and Medicaid programs require the client to have a face-to-face (F2F) encounter with their physician. The face-to-face encounter must be related to the primary reason the beneficiary requires the medical equipment and the visit must occur within 6 months from the date of the prescription.
PLEASE NOTE: some state Medicaid’s require the F2F to be within 6 months of delivery.
Tobii Dynavox is required to keep a copy of all documentation on file to meet state and government requirements; however a copy should be kept by both the client advocate and the client contact person.
Please send complete Funding Packet to the address listed below, or fax to 866-336-2737 or email email@example.com
Attn: Funding Department
2100 Wharton Street, Suite 400
Pittsburgh, PA 15203
QUESTIONS? Contact 1-800-344-1778 (Select option 3 for Funding)
Complete Your Funding Packet Online
Now you’re able to complete your funding packet through our new Tobii Dynavox Funding Portal! Our secure website allows you to fill out and submit the forms needed for funding online using your PC, MAC, iPad, iPhone and Android products.
Por favor haga clic aquí para descargar los documentos para financiación en español:
(To download the funding documents in Spanish please click here:)