Download your funding packet – Washington
Thank you for starting your Smartbox Funding application
The forms you need to complete are available to download below. You can download them each individually or as a complete .zip file. Depending on your state and funding option, more forms maybe provided.
Please make sure you read each document and complete everything required. A member of the Smartbox team will be in touch to confirm your details and offer any assistance.
Download the Smartbox Funding packet
Contained in the .zip file are 8 PDF forms that need to be completed for a funding application.
Download the Washington Medicaid forms
These additional forms need to be completed for a Medicaid application.
Help with your application
For additional assistance you can get in contact with us and we are be happy to help with any questions regarding your funding application. If you need an individual form you can download each below.
Phone enquiries: (844) 341-7386
Form 1: Client information form
This document should be filled in with the clients complete information. This also includes information on diagnoisis, family or legal guardian contact, SLP or evaluator information, treating physician information, insurance information, equipment requested and shipping information.
Form 2: Lifetime Release / Assignment of benefits / Payment Agreement
Read and complete this form to confirm the release of medical and other information nessessary to complete the funding application.
Download the Lifetime Release / Assignment of benefits / Payment Agreement form (PDF)
Form 3: Speech Generating Device (DME) Prescription
This form is to be completed by your physician. Please note the requirements on page 2.
Download the Speech Generating Device (DME) Prescription form (PDF)
Form 4: SGD Evaluation Criteria
This document informs you of the criteria that must be met for the application to be considered. Please read this carefully and ensure your application meets the criteria.
Form 5: About your device
This document describes where to find more information on Smartbox devices as well as warranty, repair information and returns.
Form 6: Patient Bill of Rights and Responsibilities
This document outlines the patient’s rights, responsibilities as well as the suppliers rights.
Download the Patient Bill of Rights and Responsibilities (PDF)
Form 7: Complaint Procedure / Emergency Preparedness
This form describes how to place a complaint and lays out Smartbox’s emergency preparedness information.
Download the Complaint Procedure / Emergency Preparedness form (PDF)
Privacy Notice
This form explains our commitment to your privacy and outlines how your information is used to process your application.
