Audiologist Application 7.1.2025

APPLICATON

Audiologist Section
Audiologist Information
Audiologist Name
Audiologist Email Address
example@example.com
Audiologist Phone Number
Format: (000) 000-0000.
Parent/Guardian Name
Patient name
Patient DOB
HEARING HISTORY
Age of Identification
Type of Hearing Loss
Degree of Hearing Loss
Newborn Hearing Screening
HEARING AID REQUEST
Requested make, model and receiver strength.
Left Device
Right Device
The following documents can be uploaded by the parent or the audiologist. If you are including any of the below documentation, please check the appropriate boxes.
File Upload

Cancelof
Participating Audiologist Signature
*I affirm that I have investigated other possible sources of funding for this patient. I understand that I should return HAAPI devices to the program when they are no longer needed.*
Today's Date

MonthDayYear
Date
Should be Empty:

APPLICATON