PARENT APPLICATION

APPLICATION
Parent Application
Full Name of Patient
DOB
Current Age
Phone Number
Format: (000) 000-0000.
Full Address
Cite, State, Zip
Gender
Ethnicity
Name of Person Filling out Application

First NameLast Name
Relationship to Patient
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 $ Type a label per hearing aid.
DEVICE AND COMMUNICATION
Does the child currently have hearing aids?
Age of hearing aids in years
Current Status

Other
What is the family’s chosen mode of communication?
SCHOOL INFORMATION
School Name
School District
Grade
Student has a(n)
School accommodations and services received

Other
PROVIDER INFORMATION
Last Audiologist Seen
Participates in the HAAPI Program?
If No, who is your HAAPI Participating Audiologist?
Name
Phone Number
Format: (000) 000-0000.
PROGRAM INFORMATION
Have you received hearing aids through HAAPI in the past?
If yes, what month/year?
*Please return HAAPI devices to the program when they are no longer needed.*
REFERRAL INFORMATION
How did you hear about this program?

Other (Please Describe)
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.
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. I give consent for the Hearing Aid Assistance Program of Indiana (HAAPI) to share this HAAPI application, required documents, and supplemental documents and hold discussions with Indiana Children’s Special Healthcare Services.
Will you be attaching your child's CSHCS card?
File Upload

Cancelof
- I affirm that all 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 HAAPI administrative staff will discuss my application with the audiologists 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.
Parent/Legal Guardian Signature
Parent/Guardian Name
Date

MonthDayYear
Date
Should be Empty:

APPLICATION

Parent Application

COST PARTICIPATION STATEMENT

DEVICE AND COMMUNICATION

SCHOOL INFORMATION

PROVIDER INFORMATION

PROGRAM INFORMATION

REFERRAL INFORMATION

SUPPLEMENTAL DOCUMENTS