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/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)*:

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 *

Month Day Year
Date
1010 N. Davis Street, Suite 101, Jacksonville, FL 32209

tel: 904.355.3403 fax: 904.355.4143
Should be Empty:

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