HAAPI APPLICATION: Parent Section

Parent Section

HAAPI APPLICATION
PATIENT INFORMATION
Patient Name*
Patient's Current Age*
Patient's Date of Birth*

MonthDayYear
Date
Patient's Gender
Patient's Ethnicity
Patient Street Address with City, State, and Zip Code*
Parent/Guardian Name*
Parent/Guardian Phone Number*
Parent/Guardian Email Address*
example@example.com
COST PARTICIPATION STATEMENT
We have # blanks* people in our home and our total gross income for all adults in the household is $ blank . Based on the sliding fee scale, we expect to pay $ per hearing aid.
HEARING HISTORY
Age of Hearing Loss Identification
Newborn Hearing Screening Results

PassFailUnknown
Degree of Hearing Loss in LEFT Ear*

NoneMildModerateSevereProfound
Degree of Hearing Loss in RIGHT Ear*

NoneMildModerateSevereProfound
Type of Hearing Loss in LEFT Ear*

NoneSensorineuralConductiveMixedAuditory Neuropathy
Type of Hearing Loss in RIGHT Ear*

NoneSensorineuralConductiveMixedAuditory Neuropathy
DEVICE AND COMMUNICATION
Does the child currently have hearing aids?

YesNo
Age of hearing aids in years:

0-34-67+
Current status of hearing aids:

WorkingBrokenLostOther
What is the family's chosen mode of communication?

Spoken LanguageSign LanguageTotal CommunicationCued Speech
SCHOOL INFORMATION
Grade
School Name
School District
Student has a:

IEP504 PlanNeither
School accommodations and services received:

Extended TimeFM SystemPreferential SeatingOther
PROVIDER INFORMATION
Last Audiologist Seen:*
Phone Number: *
Does this provider participate in the HAAPI program?*

YesNo
If No, who is your HAAPI Participating Audiologist? *
Phone Number*
PROGRAM INFORMATION
Have you received hearing aids through HAAPI in the past?*

YesNo
If yes, when did your child receive hearing aids through HAAPI?
*Please return original devices received to HAAPI administrators when new devices are fit.
REFERRAL INFORMATION
How did you hear about this program?

FlyerOnline SearchAudiologistSpeech TherapistSchoolTeacher of the DeafOther
REQUIRED DOCUMENTS
Please remember applications will be processed in order of completion only after all required documentation has been received. This application will not be processed without the following documentation.

If you cannot upload your documents here, please email them to info@haapindiana.org or fax to 888-887-0932.
Please upload Medical Clearance for Hearing Aids.

Medical clearance for hearing aids dated within 6 months of the application date signed by an M.D. or D.O.
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Please upload an Audiogram completed and dated within 6 months here.

Audiogram completed and dated within 6 months of application date.
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Please upload a birth certificate for children not yet in kindergarten or proof of school enrollment for school-age children.

Birth certificate for children not yet in kindergarten or proof of school enrollment for school-age children.
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Please upload three consecutive pay stubs for all working adults in the household. If self-employed, the most recent tax return will be accepted.

Three consecutive paystubs for all working adults in the household. If self-employed, the most recent tax return will be accepted.
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SUPPLEMENTAL DOCUMENTS
Children's Special Health Care Services ID Card: If the applicant is covered by Children's Special Health Care Services (CSHCS) with hearing loss as their eligible condition, the family has the option to submit their ID card with their application to have cost participation covered.
Please upload Children's Special Healthcare Services ID card if applicable.

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- I affirm that all the information in this application is true to the best of my knowledge. I understand that all information here will be shared with the Indiana Department of Health.
- I understand that HAPPI administrative staff will discuss my application with the aduiologists listed on this application and that this release does not permit the disclosure of these records to any other persons or entities without my written consent or as permitted by law.
- I understand that audiologists will NOT bill me for hearing aids, fitting fees, or my insurance deductible.
Name*

First NameLast Name
Signature*

Clear
Current Date*

MonthDayYear
Date
Should be Empty:

Parent Section

PATIENT INFORMATION

COST PARTICIPATION STATEMENT

HEARING HISTORY

DEVICE AND COMMUNICATION

SCHOOL INFORMATION

PROVIDER INFORMATION

PROGRAM INFORMATION

REFERRAL INFORMATION

REQUIRED DOCUMENTS

SUPPLEMENTAL DOCUMENTS