Hearing Aid Financial Assistance Form

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/White African American/Black Asian/Pacific Islander Hispanic Native American Other

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)*:

	Bill	Amount
1
2
3
4
5
6
7
8
9
10

Do you own or rent?

Own Rent Other

Does the patient have insurance?

Yes No

Insurance Company

Have you been denied insurance coverage for requested treatment?

Yes No

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 *

Date

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

tel: 904.355.3403 fax: 904.355.4143