PARENT APPLICATION

APPLICATION
Parent Section
Name
Current Age
DOB
Gender
Ethnicity
Full Address
Parent/Guardian Name
Phone Number
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?

YesNo
Age of hearing aids in years

0-34-67
Current Status

WorkingBrokenLostOther
What is the family’s chosen mode of communication?

Spoken LanguageSign LanguageTotal CommunicationCued Speech
SCHOOL INFORMATION
Grade
School Name
School District
Student has a(n)

IEP504 PlanNeither
School accommodations and services received

Extended TimeFM SystemPreferential Seating
Other
PROVIDER INFORMATION
Last Audiologist Seen
Phone Number
Participates in the HAAPI Program?

YesNo
If No, who is your HAAPI Participating Audiologist?
Name
Phone Number
PROGRAM INFORMATION
Have you received hearing aids through HAAPI in the past?

YesNo
If yes, when did your child receive hearing aids through HAAPI?
*Please return original devices received to HAAPI administrators when new devices are fit.
REFERRAL INFORMATION
How did you hear about this program?

FlyerOnline SearchAudiologistSpeech TherapistSchoolTeacher of the DeafOther (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.
Medical clearance for hearing aids dated within 6 months of application date signedAudiogram completed and dated within 6 months of application date.Birth certificate for children not yet in kindergarten or proof of school enrollmentThree consecutive pay stubs for all working adults in the household. If self-employed,
File Upload

Cancelof
SUPPLEMENTAL DOCUMENTS

Children’s Special Health Care Services ID Card: If the applicant is covered by Children’sSpecial 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.
Adult Name
Relationship to Child
Clear
Date
- 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

Clear
Date

MonthDayYear
Date
Should be Empty:

APPLICATION

Parent Section

COST PARTICIPATION STATEMENT

DEVICE AND COMMUNICATION

SCHOOL INFORMATION

PROVIDER INFORMATION

PROGRAM INFORMATION

REFERRAL INFORMATION

SUPPLEMENTAL DOCUMENTS