InTouch Networks

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Registration for InTouch Networks^SM Over the Air


There is a 1-time fee of $125 for the InTouch radio receiver. If you have Medicaid, the receiver will be covered for free. After completing the registration form below, please mail or fax a copy of your Medicaid card to InTouch Networks. If you do not have Medicaid, please mail your payment to InTouch Networks or call our office with credit card information. The receiver will be mailed to the address you provide below once payment is recieved or upon verification of Medicaid coverage.

* required

First Name: *
Middle Name:
Last Name: *
Suffix:
Address 1: *
Address 2:
City: *
State: *
Zip/Country Code: *
Country:
Home Phone: *
Work Phone:
Cell Phone:
E-mail: *
Age:
Sex:	Female Male


In order to receive this service, we must be able to determine under the U.S. Copyright laws that you are unable to read normal printed material. May we contact a competent authority to verify your inability to read normal printed material? * Yes No

If no, we will be unable to provide this service to you. If you would like to talk with someone, please call 1-800-456-3166 or 212-769-6270.

Please indicate the vision and/or physical problem(s) that makes you unable to read normal printed material: * Check all that apply	Glaucoma
	Cataracts
	Diabetic Retinopathy
	Macular Degeneration
	Other Vision Problem (Please describe)
	Physical Disability (Please describe)
How long have you had this vision and/or physical problem?
Doctor First Name: *
Doctor Middle Name:
Doctor Last Name: *
Doctor Address 1: *
Doctor Address 2:
Doctor City: *
Doctor State: *
Doctor Zip/Country Code: *
Doctor Country:
Doctor Phone: *
Doctor E-mail:
Doctor Fax:

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