Free Hearing Loss Certification - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-22554 (07/2008)

STATE OF WISCONSIN

HEARING LOSS CERTIFICATION
Telecommunications Assistance Program
Use of form: Completion of this form meets the requirements of s. 46.92, Wisconsin Statutes. Personally identifiable information on this form will be used to determine eligibility for services and will be used only for this purpose. Name - Applicant (Last, First, Middle) Telephone Number

Address - (Street)

Date Examined (mm/dd/yyyy)

Address - (City, State, Zip Code)

I examined the person named above on the date shown and have found him / her to possess a hearing loss significant enough to be considered: (check one) Deaf Severely Hard of Hearing Hard of Hearing Person Verifying Information Name

Title (Use one of the titles listed below.)

Address - (Street)

Address - (City, State, Zip Code)

Telephone Number

SIGNATURE - Person Verifying Information

Date Signed (mm/dd/yyyy)

Note:

This certificate must be completed by one of the following: 1. 2. 3. 4. 5. Licensed physician Certified audiologist DVR counselor Independent Living Center counselor ODHH Regional Coordinator

TEPP Application Number: Questions? Call 608-266-3118 Distribution: Mail completed copy to ODHH, Rm. 451, 1 West Wilson St., P.O. Box 7851, Madison, WI 53707-7851; or Fax it to 608-266-3386.