AUDIOLOGY REFERRAL REQUEST

AUDIOLOGY REFERRAL REQUEST

Michigan Department of Labor and Economic Opportunity Michigan Rehabilitation Services
District Office Information
Counselor Name
Date of Request

MonthDayYear
Date
District Office Address (No. & Street)
City
State
Zip Code
Telephone Number
Customer Identification
Customer Name
Telephone Number
Address (No. & Street)
City
State
Zip Code
Audiologist Identification
Audiologist Name
Telephone Number
Address (No. & Street)
City
State
Zip Code
The above-named individual is being referred to you for

Hearing Assessment
- Please provide a report that includes:
- Audiogram
- Speech Reception Threshold
- Pure Tone Average and Bone Conduction
- Nature, Type and Severity of Hearing Loss
Important: Please describe in your report how the hearing loss limits the individual’s ability to conduct his/her essential training or job functions as identified by the MRS counselor below:
Hearing Aid Recommendation
Please provide your written recommendation for hearing aid(s) below:
Type of Hearing Aid
Make and Model of Hearing Aid
Location(s) of Hearing Aid(s)

Right EarLeft EarBehind the EarReceiver in the Canal (RIC)Custom
Options/Features

TelecoilDirectional MicrophoneMulti-MemoryWirelessBluetooth ConnectivityAdditional Options/Features
Please provide rationale for recommendation (what makes this hearing aid essential for customer’s employment – if more room is needed, please attach additional pages.
Additional Services and Costs:
Warranty Period:
Trial period in which full refund or exchange will be permitted:
Cost of hearing instrument
Maintenance or additional products included (i.e., batteries, replacement tubes, drying aid kit, etc)
Cost of fitting and follow-up services if not included above. Please specify period in which follow-up will be provided for the cost quoted (i.e., 60 days, 1 year)
Total price quotation for products and services as specified above
Is there another hearing aid that would be suitable for employment purposes at

YesNo
If so, please state make, model and cost.
Make, model
Cost
Would you be willing to fit and/or program the hearing aids if purchased from a a different vendor?

YesNo
Would the same fitting costs quoted still apply?

YesNo
If not, what is the fitting/programming cost?
CERTIFICATION: I certify the prices quoted for the service(s) and/or article(s) are not higher than those charged to other Agencies or the general public.
Audiologist's Signature

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Title of Position
Date

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Date
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AUDIOLOGY REFERRAL REQUEST

District Office Information

Customer Identification

Audiologist Identification

Additional Services and Costs: