D1382 - Request for assistive communication device and/or speech pathology apps/software

Form ID
For providers
Medical specialist
Speech pathologist

Request for Communication Device – Assistive and/or speech pathology application(s), provided through the Rehabilitation Appliance Program (RAP).

If you are using an Apple computer and want to fill out your form electronically, please download the form and open it with Acrobat 7 or later.

How can I access this form?
Form file format