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