Transcription of Replacement Claim Form
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Replacement Claim Form
Replacement Claim Form Ship To Information Fitter's Information Customer Number: Fitter's Name:_____. (Please complete all information including name & phone number) Fitter's E-mail:_____. Information YourInformation Phone #:_____ Purchase Order #:_____ Patient Information Company Name:_____ First Name: Middle Initial: Age: Address: _____. City:_____ State:_____ Zip:_____ Last Name: Your Bill To Information Medicaid Patient: Yes: Child: Yes: Age _____. Bill To Number: Medicaid # _____. Required if applicable Instrument Information RITE Model Accessories Model: _____ For RITE/ Corda2 models if accesories are not selected, none will Lost Product Information be sent with Replacement instrument. Serial Number: _____. Speaker: Standard Medium Power Intiga Serial Number: _____ Speaker Units: Color: _____ R L Domes: 1 1 6mm Power 8mm Custom product modifications: Canal lock Tamper Resistant Battery Door 2 2 8mm Power 10mm Clothing loop Removal String Other: _____ 3 3 10mm Power 12mm Assistive Listening Device: 4 4 Plus 5 5.
Replacement Claim Form How to File a Claim Requirements: Complete form above with the model, color, serial number, patient name, speaker/dome size, if applicable. Custom instruments require a new impression.
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