Hear in the Fox Cities Application

If you need help finding a clinical audiologist or paying for clinical audiology services, please email Hear in the Fox Cities directly at hear@hearinthefoxcities.org

Having insurance is not exclusionary; Hear in the Fox Cities understands that high deductibles and copays may still make the purchase of hearing aids difficult without assistance.

Hearing aid repairs and earmolds costs may be covered, separate from new hearing aid orders. Applicants are encouraged to apply for the Mini-Fund instead for assistance wiht ear molds or repairs, etc.

Hear in the Fox Cities uses a sliding fee scale which outlines general financial considerations. (Info on the Sliding Fee Scale is near the bottom of the application).

Applications will be reviewed by the board in a timely manner and the applicant contacted with a decision. The audiologist will need to send us a quote and audiology information.

Hear in the Fox Cities will provide funding for hearing aids as long as the funds are available. We reserve the right to change eligibility at any time without written notification.

Patient Name*

Name

Gender*

Patient Date of Birth*

Date

Your name*

Relationship to patient*

Insured Person*

Insured Date of Birth*

Date

Your Email*

Your Phone #*

Preferred method of contact*

call, text or email

I need help with

How many members in household?*

numbers only

Does the patient have Medical Insurance?*

YESNO

Is there Hearing Aid Coverage?*

YESNO

What is the Insurance Company Name

ID

Group

Employer of Insured

Insurance Information - Secondary (if applicable)

Insurance Company Name

ID

Group

Employer of Insured

By signing below, I am giving permission to release records relating to Audiology and other records related to my child's hearing and to contact the applicant's health insurance about eligibility notices and information on coverage for hearing aids.

Patient Name*

Parent/Legal Guardian Name*

Signature*

Date*

Date

Please document financial hardship by providing income and expenses such as medical bills, mortgage/rent, loss of income, auto loan, student loans, daycare etc and/or other extenuating circumstances. If you need to provide additional information, please email us at hear@hearinthefoxcities.org*

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Hear in the Fox Cities recognizes the need to ensure the welfare and safety of all young people receiving hearing aid donations. We would be grateful if you would give us permission to take photos or videos of your child and use these in our printed and online publicity. I grant full rights to use the images resulting from the photography/video filming, and any reproductions or adaptations of the images for fundraising, publicity, or other purposes to help achieve the group's aims. This might include, but is not limited to, the right to use them in printed and online publicity, social media, and press releases. I give Hear in the Fox Cities permission to take photographs and/or or video of my child.

Parent/Legal Guardian Name

Signature

Date

I do not give Hear in the Fox Cities permission to take photographs and/or video of my child.

No permission

Name of Audiologist/Practice Facility*

Facility Address*

Audiologist/Facility Phone #*

HEAR IN THE FOX CITIES SLIDING FEE SCALE

This is our policy to provide discount services to those in need. It is designed to provide free or discounted care to those who have no means, or limited means, to pay for hearing care services such as hearing aids, hearing exams, ear molds and/or repairs.

Hear in the Fox Cities will offer a Sliding Fee Scale to all who are unable to pay for the hearing care services. Eligibility will be based on a person's ability to pay and will not discriminate on the basis of an individual's race, color, sex, national origin, citizenship, disability, religion, age, sexual orientation, or gender identity. The Federal Poverty Guidelines are used in creating and annually updating the sliding fee schedule to determine eligibility. The following guidelines are to be followed in providing the Sliding Fee Scale 1. Link of the Sliding Fee Scale will be listed on the hearing aid application. 2.The Sliding Fee Scale determination will be reviewed by the Hear in the Fox Cities board. Confidentiality will be respected for all who complete the application. 3. Those with incomes at or below 200% (x2) of the federal poverty level (FLP) according to the latest Federal Poverty Guidelines will receive a full 100% discount. Those with incomes above 200% FLP, but at or below 400%, will be charged a percentage fee of patient/family responsibility. The minimal fee is 10%. Everyone's sliding fee scale will vary. Families with extenuating circumstances, such as recent unemployment, extraordinarily high medical bills, or other bills will be considered. Hear in the Fox Cities will take into consideration family circumstances. Those with incomes above 400% FPL with extenuating circumstances are still encouraged to apply. 4. The responsible party must provide one month of household income (ie. earnings, unemployment, compensation, workers compensation, Social Security, alimony, child support etc You may also include in email to hear@hearinthefoxcities.org any extenuating circumstances or financial hardships as you see fit.

5. The Sliding Fee Scale program determination will be provided to the applicant and will include the amount the patient's family is responsible for or if applicable, the reason for denial. Applicants will be notified of the board's decision including any financial responsibility, within a 2- 3 week timeframe.

Hear in the Fox Cities wants families to qualify for this program. Every child or young adult under the age of 21 in our community who needs hearing aids, ear molds, a hearing exam, or hearing aid repairs is encouraged to apply.

Federal Government guidelines can be found here: https://www.dhs.wisconsin.gov/medicaid/fpl.htm

TO BE COMPLETED BY THE PARENT/GUARDIAN

VIDEO AND PHOTOGRAPHY CONSENT