Hearing Aid Assistance Program

YOU MUST APPLY PRIOR TO RECEIVING SERVICES TO BE ELIGIBLE FOR THE PROGRAM

This program covers $2,600 per hearing aid every 4 years.

If the patient establishes the medical necessity for bilateral hearing aids, two will be covered at the above benefit level.

Documentation of Medical Necessity from the doctor must be submitted with the application.

The Hearing Aid Program is considered the PAYER OF LAST RESORT. This means all other insurance must be billed prior to the Hearing Aid Program issuing payment.

The patient is responsible for completing and submitting this application in its entirety, including submitting any insurance information, and the Documentation of Medical Necessity (hearing test).

- For reimbursements, also include the provider invoice and proof of payment

Expectations of Patient:

- The patient will participate in the periodic maintenance of the hearing aid units including cleaning, adjustments, and battery changes.

- The patient will notify their hearing aid provider of any issues or problems that need to be addressed within 30 days of receiving the unit.

If approved, the approval will be valid for 6 months from the date of the approval letter or until the end of the calendar year. If you do NOT use your benefit in the allotted time, the funds will be released back into the program, and you will need to reapply to access funds.

Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address

Phone number *

Preferred contact method *

Enrollment number *

Date of Birth *

Payment method: *

NOTE: If approved, you will be issued an approval number that obligates this benefit for your use. This approval will be valid for 6 months from the date of the approval letter. If you do not use your benefit in the allotted time, the funds will be released back into the program.

Expectations of Patient:

The patient will participate in the periodic maintenance of the hearing aid units including cleaning, adjustments, and battery changes.
The patient will notify their hearing aid provider of any issues or problems that need to be addressed within 30 days of receiving the unit.