FUNDING DIRECTORY Documentation Requirements & Forms Where do I begin? Medicare criteria for Speech Generating Devices Where to send completed forms Locate your ZYGO equipment health plan provider in your state Rental Program Information Funding FAQ Glossary of terms AAC and Funding Resources SUBMIT CLAIMS FOR EQUIPMENT Client Profile Assignment of Benefits Consent Form Sample Evaluations Physician’s Prescription Sample Speech Therapists Evaluation

DOCUMENTATION REQUIREMENTS  & FORMS Funding a ZYGO communication device through Medicare, state medical assistance programs or private insurance may seem like an overwhelming task. The funding information in this section of our website is designed to walk you through the funding process, and provide you with the information and forms you need for this process. The paperwork generated from this process should be bundled together and sent to your funding resource, whether it is directly to ZYGO Industries, Inc. or to our local authorized dealer in your area. ZYGO or the local dealer then submits the claim on your behalf to the appropriate funding source. To be eligible to receive equipment through insurance, your equipment provider must receive these items prior to delivering equipment to the client. This applies to Medical Assistance funded purchases, rentals, and repairs (must provide month and year of purchase.) Signed originals need to be submitted to ZYGO Industries, or our local authorized dealer, in order for ZYGO to submit a claim on your behalf. Documentation Required: Completed Client Profile Copy of all insurance cards (front and back) Assignment of Benefits signed by client Consent Form, signed by client Speech Therapist's Comprehensive evaluation (must be dated prior to date of prescription) Physician's prescription (must be dated prior to date of delivery), must include doctor's UPIN, diagnosis, length of need and an itemized list of equipment Co-pay and deductible if there is no secondary insurance