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Commercial insurance only orders must be COMPLETE and received by PRC-Saltillo on or before November 1, 2022 to allow for processing in this calendar year. Please note: this deadline does not guarantee shipment of the device before December 31.


Due to current lead times, the purchase process is unlikely to be completed before the end of year for new trial applications. Questions? Contact your consultant.

The person trialing the communication device must be actively working with a speech therapist throughout the trial to qualify for this program. If the person trialing the device will NOT be receiving speech therapy during the summer months, please wait until the fall to request a trial device. Questions? Contact your consultant.

Welcome!

PRC-Saltillo's Trial Device Program is the ideal solution for those looking to trial a device before purchase. The program provides FREE trial equipment for four (4) weeks, with an option to extend if purchase paperwork is submitted within the time frame allowed.

Borrow a Device…Keep the Device

Like the device? The trial program can be extended for four (4) additional weeks if funding is pursued.

All necessary paperwork must be submitted via secured fax or the AACFunding.com document uploader to PRC-Saltillo's Funding Department within the four-week extension period.

The trial period will be extended again, once all funding paperwork has been received.





Please Note:

  • Once you begin completing the form, you cannot save your progress. Please be sure to have all information ready (insurance, equipment selection, SLP info) before you begin.
  • Be sure to keep the box your trial device was shipped in. Should you need to return the device, you'll need to send it back in its original packaging.
  • If trial device is not returned, late fees may apply.


Client Information (Device User)

required

 As listed on insurance card
 As listed on insurance card

 We cannot ship to a P.O. Box
 Please verify DOB



 We request this information in the event we are not able to contact you via phone or email and need to get in touch.
 Please use the email address you'd like to use to receive tracking updates and delivery notices.

Client is diagnosed with ALS or other degenerative disease

Client is diagnosed with Autism

Current place of residence

Home

Skilled Nursing Facility

Nursing Facility

Custodial Care Facility

Assisted Living

Group Home

Intermediate Care Facility

 Some insurances will not pay based on place of residence. Your PRC-Saltillo representative will work with you in case of this event.


Delivery Address same as above



Delivery Information

required

 We cannot ship to a P.O. Box




Speech Language Pathologist (SLP) Information

required






Ship Package to SLP



Payment / Insurance Information

required

Insurance Cards

It may be necessary for funding to ask for a copy of your insurance cards if there is an insurance benefit concern. We want to ensure you have the necessary coverage before you start the process. Scanning and uploading your cards will insure you get your trial device as soon as possible.

If you can scan and upload a copy of your cards now, do so below. A link to the file uploader will also be provided in your email receipt once you submit your trial order. You can upload a copy of your cards at that time via the link.


Drop files or click here to upload copies of your insurance cards.
Image files or PDFs only.

Choose all that apply:

Medicare

Medicaid

Insurance

Additional Insurance


 Medicare






 Medicaid



 Insurance




 Additional Insurance



More insurance, Medicare or Medicaid?

 Add more options to the left

United Healthcare (UHC) requires an authorization and additional paperwork for a 90-day trial


Roles and Responsibilities

required

Speech Therapist (SLP)

  • Guides the trial and provides training at time of equipment set up.
  • Is responsible (with parent/caregiver support) for helping to get all the necessary paperwork that will be submitted to insurance if the team decides to purchase the device. See aacfunding.com for more information on what funding paperwork is required in each state.

Parent/Caregiver

PRC-Saltillo

  • Provides client with a trial device and works with your insurance company to verify benefits and submit need paperwork for coverage if purchase is pursued.
  • Will assist as needed with transfer of information from trialed device to new device.
  • PRC-Saltillo consultants provide set up and training upon request. (www.prentrom.com/education (for PRC products) or www.saltillo.com/training (for Saltillo products).
  • Provides technical service and support with trialed and purchased equipment.
  • Will send the trial device with a return label included in the box to make it easier to return the device.

Terms & Conditions

required

In order to receive a trial device, this online application must be completed in full.

The initial trial period for loaned equipment is four weeks. If the trial equipment is selected as the appropriate communication solution and the decision to pursue funding is made, the trial period can be extended up to four (4) weeks pending submission of funding paperwork. Once PRC-Saltillo is notified of the decision to pursue purchase of new equipment, all of the necessary funding paperwork must be submitted to PRC-Saltillo as soon as possible and no later than four (4) weeks. PRC-Saltillo cannot submit incomplete funding submissions. If funding paperwork is not submitted at the end of the extended trial period, the trial equipment must be returned. Once all of the necessary funding paperwork is submitted to PRC-Saltillo, so that a complete funding packet can be submitted to the funding source, the trial loan period can be extended until the funding source approves or denies. If PRC-Saltillo has made several attempts at working with you to resolve missing data, and there is no forward movement to resolve those issues, PRC-Saltillo has the option of asking for the trial device to be returned.

Devices on loan through the Trial Device Program may not be taken outside the United States.

Only upon receipt by PRC-Saltillo of funding approval, can new equipment can be shipped. At that point, the trialed equipment must be returned to PRC-Saltillo. If the funding source denies and other payment options are not available, the trialed equipment must be returned. Trialed equipment must be returned at one of the following times:

  1. At the end of the four-week trial period if purchase of new equipment is not pursued.
  2. If all required funding paperwork is not provided to PRC-Saltillo within four weeks of purchase decision.
  3. Upon funding approved and receipt of new device or when funding is denied and no other funding options are available.

If trialed equipment is not returned in accordance with this agreement, the client/parent/caregiver (responsible party) will be liable for late fees. A late fee of $125.00 per week will be charged if all trial equipment is not received by PRC-Saltillo at the agreed upon return date. A minimum charge of $125.00 will be assessed to all late returns. Damage, loss, or theft of the trialed equipment is the responsibility of the responsible party to this agreement.

Optional accessories may be available and must be requested separately. Damage, loss, or theft of a trial device is the responsibility of the person who signs this agreement or of the entity represented by signature on this agreement.

    By initialing below:
  • I understand and agree to these Terms & Conditions.
  • I also certify that I am over 18.
  • I have reviewed the Notice of Privacy Practices. I am aware of my rights. I understand that I may contact the HIPAA Privacy Officer if I have questions about the content of this policy,

Download a copy of the Roles & Responsibilities and Terms & Conditions for your records.
Descargue una copia de los roles y responsabilidades y los términos y condiciones para sus registros.



Responsible Party

Must be over the age of 18
required

Same as Client Information




 Ex. (555) 555-5555
 Ex. (555) 555-5555

I have read and understood this agreement and I am over the age of 18.


required

Your Device

Choose one

Accent Devices

Accent 800

Language:

Unity, LAMP, CoreScanner & Engage

Access:

Accent 1000

Language:

Unity, LAMP, CoreScanner & Engage

Access:

Accent 1400

Language:

Unity, LAMP, CoreScanner & Engage

Access:

NovaChat Devices

NovaChat 5

Language:

NovaChat 8

Language:
Wrap Option:
Ships with Active

NovaChat 10

Language:
Wrap Option:
Ships with Active or Classic based on availability

Via Devices

Via Pro

Supply chain issues are negatively impacting availability of the Via Pro. Trials are limited to those requiring insurance authorizations and/or certain bilingual features. Please select from the dropdown below or make another device selection.
Includes LAMP Words for Life, TouchChat, and Dialogue AAC. Select the app that you are most interested in trialing.


Wrap Option:
Ships with Active
Bilingual?

PRiO-mini

Consideration for Via Mini:
Learn More
Language:
Bilingual Spanish/English
Wrap Option:
Ships with Classic

TouchChat Express 8

Consideration for Via Mini:
Learn More
Language:
Bilingual Spanish/English
Wrap Option:
Ships with Classic

 Due to limited availability on new models, an older model may be substituted for a request. Some high demand products may take longer to ship than others.

Keyguards & TouchGuides

What's the difference between Keyguards and TouchGuides?

No options available. Please select a device to show potential options.
Select up to two
Keyguard
TouchGuide










Keyguard

Select up to two
Keyguard
TouchGuide






Select up to two
Keyguard
TouchGuide






Select up to two
Keyguard
TouchGuide







Select up to two
Keyguard
TouchGuide







Select what is needed, limit of two TouchGuides
Keyguard
TouchGuide








The device user is unable to access the device by pointing and selecting buttons. He/She requires an alternative access method such as eyegaze, head pointing, and or switches.

Accessories


Switch

Choose up to two (includes extras)

Aero Switch

Optional:

Freedom Switch

Optional:

Liberator Switch

Optional:

Mounts

Choose only one

Table Stand

Floor Stand

ClampOnMount

Not recommended for attachment to a wheelchair

You're almost done!

Please confirm your choices, then click submit down below.




Before clicking “Submit,” please review your information to ensure it is correct.

Upon receipt of your request, a confirmation will be sent to the email provided. Please be sure to look it over carefully to confirm all information is correct.

We look forward to working with you!



Thank you!

Your request has been submitted.


If you have any further questions or concerns please don't hesitate to get in touch with us at info@prentrom.com.

A confirmation has been sent to your email, thanks again!

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