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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.

Smartbox funding application (PDF)

Download the Washington Medicaid forms

These additional forms need to be completed for a Medicaid application.

Washington Medicaid forms (PDF / Word)

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.

Email our team

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.

Download the client information form (PDF)

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.

Download the SGD Evaluation Criteria form (PDF)

Form 5: About your device

This document describes where to find more information on Smartbox devices as well as warranty, repair information and returns.

Download the About your device form (PDF)

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.

Download the Privacy Notice

Request a quote

Quickly put together what you need and send it over to us.

Request a quote

Mailing list

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You can change your mind at any time by clicking the unsubscribe link in the footer of any email you receive from us, or by contacting us at hello@thinksmartbox.com.

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