DELAWARE HEALTH AND SOCIAL SERVICES Division of Public Health DELAWARE HEARING AID LOAN BANK HEARING AID LOAN APPLICATION FORM The purpose of this program is to provide temporary hearing aids for children under 18 with hearing loss while they are waiting to receive their personal amplification devices. Please contact the Hearing Aid Loan Bank at (302) 744-4544, if you have any questions. Please complete Parts A-D of this application and return to: Newborn Hearing Screening Program, 417 Federal Street, Dover, DE 19901 The information contained on this form will be kept confidential. PART A Referring Audiologist Information Audiologist’s Name: _____________________________________________________________ DE Audiology License #_________________________________________________________ Mailing Address: ________________________________________________________________ ________________________________________________________________ Phone Number: _____________________________Fax Number: __________________________ Child’s Information Name: ____________________________________Date of Birth: ________________________ Parent/Legal Guardian’s Name: ___________________________________________________ Mailing Address: ________________________________________________________________ ________________________________________________________________ Phone Number: ___________________________________________________________________ Email Address:___________________________________________________________________ PART B To be completed by the referring audiologist In order for this request to be processed, a copy of any audiologic testing, medical clearance from the child’s ENT, and an agreement form signed by the parent or legal guardian must be provided with this application. Please make copies or fax, as this paperwork will not be returned. Was this child referred to you based upon failure of the Universal Newborn Hearing Screening protocol? Yes____ No____ If yes, from which hospital _______________________________ What is the configuration (if known) and degree of hearing loss? Is this a binaural or monaural fitting? _________________ Please indicate using the list below the make and model of hearing aid that you would recommend for this child, numbering preferences 1-3. While we cannot guarantee the exact make and model, please be assured that every attempt will be made to match your request. Also indicate the target gain desire. Manufacture’s specifications are available on request. __________________________________ ___________________________________ __________________________________ ___________________________________ __________________________________ ___________________________________ __________________________________ ___________________________________ __________________________________ ___________________________________ The hearing aid(s) will be sent to the requesting audiologist within 3 days of receiving the application and required documentation. The hearing aid will be selected and sent by the Hearing Aid Loan Bank Audiologist based on the information received. ______________________________________ ________________ Audiologist Signature Date PART C To be completed by the parent or legal guardian 1. Please provide a brief statement indicating the reason assistance from the loan bank is requested. ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ 2. Do you currently have insurance coverage to secure permanent hearing aids for your child? If yes, have you contacted your insurance company to apply for hearing aids? Please indicate the insurance company name, and the status of your contact. ______________________________________________________________________ ______________________________________________________________________ 3. Are you currently eligible for Medical Assistance? If yes, have you contacted Medical Assistance to apply for hearing aids? ______________________________________________________________________ ______________________________________________________________________ 4. Do you need information regarding resources to secure permanent hearing aids? ______________________________________________________________________ ____________________________________ ______________________ Signature of Parent/Legal Guardian Date Address __________________________ Phone__________________ __________________________ PART D HEARING AID LOAN AGREEMENT _______I AGREE THAT MY CHILD WILL RECEIVE (A) LOANED HEARING AID(S) FROM THE DELAWARE STATE DEPARTMENT OF HEALTH AND SOCIAL SERVICES, DIVISION OF PUBLIC HEALTH. _______I AGREE TO PROVIDE A BRIEF STATEMENT INDICATING THE REASON ASSISTANCE FROM THE LOAN BANK IS REQUESTED. _______I AGREE THAT IT IS MY RESPONSIBILITY TO MAINTAIN AND CARE FOR THE HEARING AID(S) AND THAT I WILL BE RESPONSIBLE FOR ANY LOSS OR DAMAGE NOT COVERED BY THE HEARING AID WARRANTY UP TO $100.00. THIS EXCLUDES NORMAL WEAR AND TEAR. _______I AGREE THAT MY CHILD WILL HAVE USE OF THIS/THESE HEARING AID(S) FOR UP TO 6 MONTHS. IF MY CHILD HAS NOT RECEIVED HIS/HER PERSONAL AMPLIFICATION WITHIN THAT TIME, I MAY EXTEND THE LOAN PERIOD BY 3- MONTHS, BY COMPLETING AN EXTENSION AGREEMENT. _______ I AGREE TO SEEK PERMANENT HEARING AID(S) FOR MY CHILD. _______I AGREE THAT WHEN MY CHILD RECEIVES HIS/HER PERSONAL AMPLIFICATION, I WILL RETURN THE LOANED HEARING AID(S) TO MY CHILD’S AUDIOLOGIST, TO BE RETURNED TO THE LOAN BANK. _______________________________ _______________ Parent/Legal Guardian Signature Date