Hearing Services Application

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Hearing Services

Lions Affordable Hearing Aid Application Form

Step 1 of 4

25%

Your Personal Information

Your Name(Required)

First

Last

Birth Date(Required)

MM slash DD slash YYYY

Address(Required)

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Application Information

Insurance(Required)

Name and Policy Numbers of any/all Health Insurance Policies

List Names and Ages of Everyone in Your Household(Required)

Please list the names and ages of everyone in your household below, along with their relationship to you.

Do you wear a hearing aid?(Required)

Yes

If yes, why do you need one?

Is the Applicant employed?(Required)

Yes

If No, why?

Employer

Statement of Understanding

Consent(Required)

I fully understand these services are limited to indivduals unable to pay for or receive hearing aids from other sources of assistance. In consideration of these services, I release and discharge all persons rendering such services from any claims I may have arising from services so rendered. I am aware that a hearing aid billed to me prior to the approval of this application will not be paid for by this service.

I also understand my application may be reviewed by the Lions Club and hearing professionals. These forms will be kept on file by the local Lions, the hearing care professional and LCIF. The documents will be kept confidential and not shared with third parties, such as insurance companies.

All information on and attached to this application is true and correct to the best of my knowledge.

I understand and agree

Income & Asset Form for Candidates

Monthly Gross Income(Required)

Please list out the following gross incomes before taxes: Salary of Candidate, Salary of Spouse, Salary of Parent, Social Security Benefits, Retirement Pension, Income from Other Family, Food Stamps, Investments, Assets, Other Income & Total Monthly Income

Monthly Expenses(Required)

Please list out the following monthly expenses (on average): Rent/Mortgage, Utilities, Food, Phone, Medicine, Car/Transportation, Child Care, Home Insurance, List/Charge Cards, Other Expenses & Total Monthly Expenses

All information on and attached to this application is true and correct to the best of my knowledge.

I agree

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