TAI Applications for Wireless Devices 2023

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

YesNoNot sure
Yes, I have applied to and received equipment from Telecommunications Access Iowa before.
Type in MY HEARING HAS NOT CHANGED and initalize 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 Organization
The place where your doctor, audiologist, voc rehab counselor, etc. works.
Professional Name
The name of your doctor, audiologist, voc rehab counselor, etc.
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
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*

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

YesNo
Signature of Parent/Guardian

Clear
Parent/Guardian Signature Date

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

Do you Qualify?

Equipment Needed

Terms & Conditions

Professional Signature Required

Your Signature Required