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HEARING SERVICESA P P L I C AT I O N5582 Peachtree Road Atlanta, GA 30341 Phone: 404.325.3630 Fax: 770.406.6558

Application ChecklistPlease print clearly. Keep a copy of this application.The following MUST be submitted for this application to be considered:Failure toincludedocumentswill documentsdelay your applicationincreasethe timeandit takesto get yourhearingaids.Failuretheseto includethesewill delayandyourapplicationincreasethe timeit takesPatients are individually responsible for providing the required documents listed below.to get your hearing aids.1. Current hearing test (less than 6 months old). Must be done or approved by a Lighthouse-Foundationapprovedprovider(page 5).The followingdocumentsMUSTbe submitted:2. Lighthouse-approved Hearing Provider Recommendations (page 4).1. Current hearing test (less than 6 months old). Must be from or approved by a ge 4)hearingprovider.page 6Waiverfor more( information.Fully completedwith attacheddocumentation(see below)2. 4.CompletedProviderapplicationRecommendation(page 4 ofapplication).3. Fully completed application with supporting documents. All pages must be filled out andDocumentation:signed where appropriate. Documents are listed in the chart below. GA driver license OR GA birth certificate OR GA identification card OR GA voter’sregistrationcard OR GA Medicaid/Medicare cardSupportingDocuments: Copy of firstof rentalOR geDriverLicenseagreementOR GA IdentificationOR GAORbirthcertificateshelter,or transitionalstatingthat you live at thatlocation (on letterheadOR home,GA Voter’sRegistrationcardhomeOR GAMedicaid/Medicarecardand signed by home/shelter employee) OR notarized letter if living with family or2. Residency:friend OR copy of a current utility bill (gas, water, electric) Any of the following items that apply to you and your household: Last year’s tax return Last 3 months of bank statements 3 most current paycheck stubs Most current Social Security Award letter Most current Food Stamp award letter from DFACS Letter from nursing home Unemployment Claim/Wage Inquiry from Dept of Labor Information and documentation of other forms of income: TANF, pension, retirement, child support, etcTHE HEARING AID PACKAGE IS NOT FREE. YOU WILL HAVE A COPAYMENT.The estimated amount of time to process applications is 2 weeks.Individuals may apply once every five years for service depending on program funding.GLLF 1

Patient InformationPlease answer ALL questions. Print clearly in CAPITAL LETTERS with a dark pen.If you have any of the below, it is recommended that you consult a medical doctor first. If you do not want a medical examination, Federal Law allows a fully-informed adult to sign a waiver statement declining the medical evaluation (Page 4).1. Congenital/traumatic deformity of the ear2. Active ear drainage within the last 90 days3. History of sudden or rapidly progressive hearing loss within the last 90 days4. Acute or chronic dizziness5. Unilateral hearing loss of sudden or recent onset within the previous 90 days6. Audiometric air-bone gap equal to or greater than 15 decibels at 500, 1000, and 2000 HZ7. Visible evidence of earwax (cerumen) or any foreign body in the ear canal8. Pain or discomfort in the ear1. Applicant Name:TitleFirstMiddleLastSuffix2. Name of Parent or Guardian (if applicant is a minor):TitleFirstMiddleLastSuffix3. Address:4. City: , Georgia5. Zip Code:6. County7. Sex:8. Social Security Number: XXX - XX-MF9. Date of Birth / /10. Home Phone: ( ) - 11. Cell Phone: ( ) - 12. Work Phone: ( ) -13. Email Address :15. Are you employed?14. How long have you been a GA resident?YN16. If no, are you actively seeking employment?17. If you are unemployed, circle all that apply: Disabled/Receive SSDI18. Race:WhiteAfrican AmericanOtherUnableRetiredHispanicAsianYNLost JobOther19. Insurance: Please circle every type of insurance you have. Please be aware that we do not accept WellCare as payment.MedicareMedicaidVAPeachCareGrady CardOtherKaiserNone20. State the reason(s) why you cannot afford to purchase hearing aids:21. Marital Status:MarriedSingleDivorcedSeparatedWidowed22. How did you hear about the Lighthouse Foundation Hearing Program?GLLF 2

Financial InformationIn the chart below, list everyone - including yourself - living at your address. Include all sources of incomefor all members of the household. Attach additional household members on separate sheet or list on theback of this page.NameAgeRelationshipDependent(Yes or No)SelfNoAmount ofIncomeSource(s) of Income Total # of People inHouseholdTotal # ofDependents inHouseholdTotal Monthly Income(Combined income forall members of household)Monthly ExpensesAssetsRent or Mortgage Savings/Checking Accounts Utilities Stocks & Bonds (Market Value)Face Value of C.D.s Value of Home/Land/Property Cars/Trucks Other Food Phone/Cable Credit Cards Insurance (include documentation)Water/Sewage Car Payment Medicine Medical Debt Additional ExpensesAdditional AssetsGLLF 3

Provider RecommendationThis section must be completed by the hearing professional who performed the hearing test.You must include a copy of that current hearing test (audiogram).The Lighthouse Foundation does not pay for hearing tests.Business Name:Name and Title of Hearing Professional:Phone Number: Fax Number:Address:City: State:Zip Code:Email Address:Please specify degree of hearing loss:MildModerateModerately SevereSevereProfoundCircle the type of hearing aids recommended:Right Ear:NoneRIC/BTEITEBICROSLeft Ear:NoneRIC/BTEITEBICROSIs this facility a Lighthouse Provider?YesNoIf no, are you interested in becoming a Lighthouse Provider? YesNoContact us at 404.325.3630 x305 or visit www.lionslighthouse.org for more information.Medical WaiverI have been advised by (audiologist/hearing aid dispenser) that theFood and Drug Administration has determined that my best health interest would be served if I had a medical evaluation by a licensed physician (preferably a physician who specializes in disease of the ear) before obtaining a hearingaid. I choose not to have a medical evaluation before obtaining a hearing aid./ /Signature of ApplicantDateWitness (if applicant signs with an “X”)/ /DateMedical ClearanceI certify that (applicant name) was medically examined on / / and may beconsidered a candidate for hearing aid use.*Must be signed and dated by a licensed physician (M.D.).Signature of M.D./ /DateName of M.D. (Please Print)GLLF 4

Lighthouse StatementPlease Read and Sign This Statement. This MUST be signed by all patients.“I fully understand Lighthouse services are limited to legal GA residents unable to pay for, or receive from othersources, this assistance. In consideration of these services, I release and discharge all persons rendering such services from any claims I may have arising from services rendered. I am aware that the Lighthouse will not pay forany hearing aids billed to me prior to approval of this application. I also understand my application may bereviewed by a Lions Club, Lighthouse Providers, and/or the Lighthouse staff.All Information on and attached to this application is true and correct to the best of my knowledge. I also understandthat the Lighthouse Foundation has the right to refuse service to any applicant.”Signature of Applicant (or parent if applicant is a child)DateWitness (if applicant signs with an “X”)DateAuthorization of Information/HIPAAEVERYONE MUST SIGN AND DATE THE BOTTOM OF THIS PAGE.Please list an emergency contact. If you want us to be able to speak with this person about your services, pleasecheck the box on the right. If you want us to speak only with you, do not check the box to the right.Emergency Contact1. Name Permission to2. Relationship to Applicant:3. Phone:4. Address:5. City6. State7. Zip Codespeak with listedcontact about yourhearing aids?I understand that the Federal Privacy Rule (HIPPA) does not protect the privacy of information if re-disclosed, andtherefore request that all information obtained by this person or agency be held strictly confidential and not be further released by the recipient. I further understand that my eligibility for Lighthouse services is not conditioned uponmy provision of this authorization. I intend for this document to be a valid authorization conforming to all requirements of the Privacy Rule and understand that my authorization will remain in effect for:Please check how long you give us permission to speak with the above-listed individual: Ninety (90) days One (1) year Until this specified expiration date: The period necessary to complete all transactions on matters related to services provided to me. I understandthat unless otherwise limited by state or federal regulation, and except to the extent that action has been takenbased upon it, I may withdraw this authorization at any time./ /Signature of Applicant (person applying for hearing services)DateSignature of Authorized RepresentativeSignature of Witness (if patient signs with an X)(Person chosen by the applicant to speak with the Lighthouse)GLLF 5

Lighthouse Foundation Approved Hearing ProvidersThere are certain hearing providers who work with the Lighthouse Foundation hearing program. Thismeans they accept payment from the Lighthouse Foundation on your behalf. It also means they abideby the guidelines of the Lighthouse Foundation program and agree to provide the services included inyour hearing aid package.For this reason, you MUST be a patient of a Lighthouse Foundation-approved hearing provider. A listcan be found on our website, www.lionslighthouse.org or by calling 404-325-3630.What does this mean if you already have a hearing test? Can you use it?Maybe. All hearing tests must be current. According to Georgia law, that means it must be 6 monthsold or less. Furthermore, if your hearing test does not come from a Lighthouse-approved provider, ourLighthouse providers may require you to get a new test from them before you can proceed to be theirpatient. If you have a current test you wish to use, you will need to ask your new Lighthouse provider ifhe/she will accept it.How do you find a Lighthouse Foundation-approved hearing provider?You can find a current list of providers at www.lionslighthouse.org, or you can call the Lighthouse Foundation at 404-325-3630 to request a list.Once you have the list of providers, please follow these three steps:1. Choose a Lighthouse Provider from the provided list.2. Call the Provider you have chosen. Tell them that you are applying to the GeorgiaLions Lighthouse Foundation for hearing aid assistance and you need a LighthouseFoundation-approved provider.* If you have a hearing test that is less than 6 months old, ask them if they willaccept it.* If you do not have a hearing test, tell them you need one.3. Ask the Provider if they are willing to accept you as a new patient. If the provideragrees to accept you as a patient, you will see this provider for your Lighthouse Foundation-approved hearing appointments.* If the provider is not willing to accept you as a new patient, choose anotherprovider from the list who is in your area and repeat the steps above.Write the name of your Lighthouse Foundation-approved hearing provider here:GLLF 6

Hearing Program Survey: Please circle or place a check mark by your choice. This is MANDATORY for you to beconsidered for services.DATE:1. What is your age?a.0-21b. 22-342. Are you a first time hearing aid user?Yesc. 35-50d. 51-64e. 65 & upNo3. Have you received hearing aid(s) from the Lighthouse Foundation before? YesNo4. How long have you experienced hearing loss?a. less than 5 yearsc. 10 to 15 yearsb. 5 to 10 yeard. more than 15 years5. How often do you experience the following symptoms? For each choose ONLY ONE of the options:Very s (Ringing or roaring in theears)Balance IssuesVertigo (dizziness)6. At the present time, would you say your overall hearing is excellent, good, fair, poor, or very poor. You may alsodescribe your overall hearing in the comment section.a. Excellentd. Poorb. Goode. Very Poorc. Fairf. Comment:7. Please circle Yes, No, Sometimes, or N/A for each statement below.YesNoSometimesN/ADoes a hearing problem cause you to feel frustrated whentalking to others?Do you have difficulty hearing when someone speaks in awhisper?Do you feel handicapped by a hearing problem?Does a hearing problem cause you difficulty when visitingfriends, relatives, or neighbors?Do you feel that any difficulty with your hearing limits orhampers your personal or social life?Does a hearing problem cause you difficulty when in a restaurant with relatives of friends?GLLF 7

8. How well are you able to do the following activities? For each activity choose ONLY ONE of the following options:With a lot of difficulty, With some difficulty, Not sure, With some ease, With great ease, or N/A.With a lotof difficultyWith somedifficultyN/AWith someeaseWith greateaseBe independentCommunicate with physician at medicalappointmentsCommunicate at employment interviewsTake care of others (children, spouse, elderly)Engage in group discussions or activitieswith friends and familyHear the doorbell or telephone the firsttime it ringsHear the smoke alarmDrive a carParticipate in hobbies and social activitiesOther (please list the name of the activity:)9. Are you a student?YesNoIf you answered yes, with your current hearing, how well are you able to do the following activities? For eachactivity choose ONLY ONE of the following options: Very well, Well, Difficult, Very Difficult, or N/AVery WellWellDifficultVery DifficultN/ACommunicate with teacher and classmatesListen to audio presentations in theclassroom/lecture hallCommunicate with others in the libraryComplete assignmentsParticipate in class discussions10. How were you referred to the Lighthouse Foundation?a. Department of Family and Children Servicesg. Vocational Rehabilitation Servicesb. APS Healthcareh. Lions Clubc. United Healthcarei. Audiologist/Hearing Aid Dispenserd. Medicaid/Medicare Specialistj. Websitee. Nursing Homek. Newspaper Articlef. Senior Centerl. Other:GLLF 8

2. Call the Provider you have chosen. Tell them that you are applying to the Georgia Lions Lighthouse Foundation for hearing aid assistance and you need a Lighthouse Foundation-approved provider. * If you have a hearing test that is less than 6 months old, ask them if they will accept it. * If you do not have a hearing test, tell them you need .File Size: 645KBPage Count: 9Explore furtherAdult Hearing Services Application - Lions Lighthouselionslighthouse.orgLions Club free glasses and hearing aidswww.needhelppayingbills.comWhere can I donate my old eye glasses or hearing aids .lionshelp.zendesk.comHow can I apply for assistance with my eyeglasses . - Lionslionshelp.zendesk.comLions Club Application for Eyeglasses - Page 1static1.1.sqspcdn.comRecommended to you b