TAI Application for Equipment

TAI Application for Equipment
Applicant Name *

First Name Last Name
Phone Number *
Please enter a valid phone number.
Email
example@example.com

Have you applied for a specialized telecommunications equipment through Telecommunications Access Iowa before? *

Yes No Not sure
Yes, I have applied to and recieved equipment from Telecommunications Access Iowa before.
Type in MY HEARING HAS NOT CHANGED and intialize it.
Professional Signature Required

If you have not applied to TAI, then you will need a professional signature to verify your hearing loss or your speech difficulty. Please enter your professional's information below, and follow the instructions on the next page on how to get verified.

You must receive a signature by your doctor, audiologist, voc rehab counselor, state or federal agency representative, or any other licensed professional in the field of hearing or speech.

The professional should be YOUR "personal" professional, such as your family doctor, a regular audiologist, a sign langauge interpreter you know. Someone that you have an established relationship with.

Their signature verifies you have a need for specialized telecommunications equipment to assist communication over the telephone.
Professional's Name
The name of your doctor, audiologist, voc rehab counselor, etc.
Professional's Organization
The place where your doctor, audiologist, voc rehab counselor, etc. works.
Professional's Phone Number *
Please enter a valid phone number.
Professional's Email *
example@example.com
Do you authorize your professional to share your information with Telecommunications Access Iowa? *

Yes, I authorize my professional to share my information with Telecommunications Access Iowa.
It is recommended that after you submit this application you reach out to your professional to let them know they will be receiving an email from Telecommunications Access Iowa requiring their verification and signature.

Your Signature Required

By my signature below, I certify that all of the above information is true. By signing this application form, I agree to participate in any follow up survey in order to assure quality customer service and satisfactory use of my equipment. I understand that I am only allowed to receive one item or package of items per family household every five years. I become the owner of the items I receive and am responsible for the maintenance and warranty. I must use the voucher at an authorized dealer by the deadline listed on the form. I agree to pay any remaining cost that is not covered by the Telecommunications Access Iowa Voucher Program.
Signature of Applicant *

Clear
Signature Date *

Month Day Year
Signature Date
Is the applicant under 18 years of age, or is the application being filled out by a guardian?

Yes No
Signature of Parent/Guardian

Clear
Parent/Guardian Signature Date

Month Day Year
Date
Printed Name of Parent/Guardian
Relationship to Applicant
i.e. Mother, Son, Power of Attorney (POA), etc.
Should be Empty:

TAI Application for Equipment

Please fill out all questions completely.

Do You Qualify?

Equipment Needed

Professional Signature Required

Your Signature Required