HAAPI APPLICATION: Audiologist Section

Audiologist Section
APPLICATION
Today's Date*

MonthDayYear
Date
Audiologist Name*
Audiologist Email Address*
example@example.com
Audiologist Phone Number *
Patient Name*
Patient Date of Birth*
Parent/Guardian Name*
Hearing Aid Request*

Unilateral (1 hearing aid)Bilateral (2 hearing aids)
Traditional hearing aids include earmold and pediatric care kit. Bone anchored hearing aids include softband. Please list requested make, model, power level & battery size.
Right Hearing Aid Requested*
Left Hearing Aid Requested*
INCLUDED DOCUMENTS
The following documents can be uploaded by the parent or the audiologist. If you are uploading any of the below documentation, please check the appropriate boxes.

Medical clearance for hearing aids dated within 6 months of application date signed by an M.D. or D.OAudiogram completed and dated within 6 months of application date.Birth certificate for children not yet in kindergarten or proof of school enrollment for school age children.Three consecutive pay stubs for all working adults in the household. If self-employed, most recent tax return will be accepted.
Please upload any files you checked above here.

Cancelof
I affirm that I have investigated other possible sources of funding for this patient.
Signature*

Clear
Name*

First NameLast Name
Current Date*

MonthDayYear
Date
Should be Empty:

Audiologist Section