Hearing Aid Financial Assistance Form

Financial Assistance
Demographic Information (MUST COMPLETE FIELDS WITH A*)
Patients Full Name *
Patients DOB*
Legal Guardian Name
Street Address*
City
State
Zip*
Phone #*
Email*
example@example.com
Ethnicity (optional)

Caucasian/WhiteAfrican American/BlackAsian/Pacific IslanderHispanicNative AmericanOther
Financial Information (MUST COMPLETE FIELDS WITH A *)
Number of family members in household*
Number of people you claim on your taxes*
Household monthly income from all sources (anyone whose income is used to pay living expenses)*

Monthly Expenses (bills or fees paid to whom and in what amount)*:

Do you own or rent?

OwnRentOther
Does the patient have insurance?

YesNo
Insurance Company
Have you been denied insurance coverage for requested treatment?

YesNo
How did you hear about this program?*
The completion of this application is not a guarantee for funding. Applications are approved on a case-by-case basis and subject to program availability. I understanding that I am applying for subsidized hearing aids through a donor funded program or grant available at JSHC for either myself or a person under my care. I understand that intentionally falsifying information is grounds for termination of services, repossession of devices and dismissal from the practice. By signing below I confirm that the information provided above is true and accurate.
Patient/Legal Guardian Signature:*

Clear
Date*

MonthDayYear
Date
1010 N. Davis Street, Suite 101, Jacksonville, FL 32209

tel: 904.355.3403 fax: 904.355.4143
Should be Empty: