Augmentative and Alternative Communication Request for Repair Form

Date __________________________________________________________________

User’s Name ____________________________ Phone Number ___________________

Mailing Address (Location device should be mailed to) ____________________________

_______________________________________________________________________

Medicaid Number ________________________________________________________

Original Purchase Date ____________________ Original Pay Source _______________

Contact Person (Person acting on behalf of user) ________________________________

Phone Number _______________________ Email Address _______________________

Device Manufacturer ________________________ Model ________________________

Serial Number___________________________________________________________

Manufacturer ____________________________________________________________

Address _______________________________________________________________

Return Authorization Number ________________________________________________

Reason for Returning Device ________________________________________________

Is device being returned to replace batteries? _____ Yes _____ No _____ Not sure

Other __________________________________________________________________

Person completing this form _________________________________________________

Phone Number _____________________ Email Address _________________________

Please send a copy of this form, along with the device, to the manufacturer.

Retain one for your records.

Follow Up Notes __________________________________________________________

_______________________________________________________________________

01/15/02