Finding the Right Insurance Provider
We can help you find the best source of funding. To begin making inquiries, we need to get an accurate estimate of your financial responsibility to purchase a device.
Potential Sources of Funding
Step-by-Step Funding Request Process
Fill out authorization forms
Please complete and return the following documents to Eyegaze Inc. for specific plan benefits.
Click on each document to the right to open it in a new window.
Complete the financial responsibility form
Submit medical forms
Regardless of which insurance provider you have, you will need to submit the following documents. Complete and forward them to Eyegaze Inc.
• SLP Report
A communication evaluation by a speech-langauge pathologist needs to document the need for a communication device.
• Physican Prescription
Physicians must provide a DME (durable medical eqipment) prescription along with clinical notes from the patient’s most recent face-to-face visit. The face-to-face visit with a physician must pre-date the physicians DME prescription form.
Note: In some instances, insurance companies require a Prior Authorization before the purchase of a Speech Generating Device, and these medical documents will need to be forwarded to the clinical department as well.
Include a copy of your insurance card
Insurance card (front and back)
Retain for your records
- Privacy Practices
- DMEPOS Standards
Submit Required Documents
Send all completed paperwork to Eyegaze Inc. via fax or mail.
10363 Democracy Lane
Fairfax, VA 22030