Download Provider-Application - Alison`s Hope For Hearing

Provider Application & Information
Alison’s Hope for Hearing is a national, non-profit 501c(3) organization that is
committed to creating and supporting programs serving the deaf and hard of hearing.
The goal of our hearing aid program is to provide accessible hearing care and
amplification to low-income and underserved populations.
We partner with hearing healthcare providers that are interested in furthering our
mission and are willing to screen, test and fit patients for a nominal fee for their
expertise and time.
Patient Referral
The patient and provider may be connected in one of two ways: 1) the patient has
visited the provider and stated that they cannot afford hearing aids and are referred to
Alison’s Hope for Hearing by the provider, or 2) the patient has sought out the
assistance directly from Alison’s Hope for Hearing and is referred to previously approved
provider.
Patient referred by provider:
1.
Patient must complete and sign Application for Assistance found on our
website
2.
Patient must submit along with application, $100 application fee
3.
Provider must supply recent audiogram (within last 6 months)
4.
Provider must supply physicians medical clearance
5.
All of the above it submitted via US Mail to Alison’s Hope for Hearing
Patient referred by Alison’s Hope for Hearing:
1.
Patient completes Application for Assistance and submits to Alison’s Hope for
Hearing
2.
Alison’s Hope representative contacts local provider to inquire as to whether
they can take on the patient referral; if so, we advise patient to call for
appointment
3.
Patient makes appointment with provider for complete audiological exam
4.
Provider conducts full audiological evaluation (air conduction, bone
conduction, speech reception thresholds, and speech discrimination testing.)
to determine candidacy
5.
Provider submits audiogram and medical waiver to Alison’s Hope for Hearing
to attach to patient’s application
Protocol for Establishing Need
Hearing Loss, Primary Communication Visual
An unaided hearing loss
•
•
of at least 40 dB (American National Standard Institute [ANSI]), or pure tone
average (PTA) in the more useful ear; or
between 30 and 39 dB loss (ANSI), or PTA in the more useful ear with either o
speech discrimination of less than 70%, or
o a statement from a physician skilled in diseases of the ear stating a
progressive loss of hearing.
The consumer's primary receptive mode of communication is visual (for example,
writing, lip reading, manual communication, gestures). The consumer's primary
expressive mode of communication is spoken language (when the consumer voices or
speaks for himself or herself).
Hearing Loss, Primary Communication Auditory
An unaided hearing loss
•
•
of at least 40 dB (American National Standard Institute [ANSI]), pure tone
average (PTA) in the more useful ear; or
between 30 and 39 dB (ANSI), or PTA in the more useful ear with either o
speech discrimination of less than 70%, or
o a statement from a physician skilled in diseases of the ear stating a
progressive loss of hearing.
The consumer's primary receptive mode of communication is auditory with or without
the assistance of amplification (for example, hearing aids). The consumer's primary
expressive mode of communication is spoken language (when the consumer voices or
speaks for himself or herself).
Other Hearing Impairments (for example, tinnitus, Meniere's disease, hyperacusis,
etc.)
Diseases and conditions of the ear or auditory systems that do not cause a hearing loss
of at least 30 dB in the conversational range in both ears, but that do cause an
impediment to employment.
Approval of Application
Once all necessary components of application have been received by Alison’s Hope for
Hearing:
•
signed and completed application
•
medical waiver
•
recent audiogram
•
$100 application fee the board will review candidate for amplification
assistance based on financial and auditory need. Both provider and patient will be
notified via US Mail of acceptance (or denial) within 6-8 weeks.
Recommendation/Request of Hearing Instruments
Provider is asked to contact Alison’s Hope for Hearing to make a recommendation as to
what product/style of hearing instruments would be best suited for patient, keeping in
mind we are looking for best value. Hearing aids (and ear molds if necessary) will then
be purchased and billed directly to Alison’s Hope for Hearing and drop shipped to
provider for fitting.
Fitting & Follow-up Care
The hearing instrument fitting consists of physical fit, programming, tubing and
adjustments of ear molds, and counseling on use in order for patient to get full benefit
of hearing instruments during their 30 day evaluation. We would also expect that the
patients follow up care include up to three (3) appointments, including adjustments,
during the one-year warranty period, and following the maximum 30-day trial period.
During the one-year period, the provider agrees to not charge the patient for any
services. Any care of the patient after the one-year period is to be negotiated between
the patient and provider.
Post 30 day evaluation, if patient is to accept hearing instruments they must sign a
“Receipt of Acceptance”. If the patient decides not to keep the hearing instruments,
those hearing instruments are to be returned to Alison’s Hope for Hearing immediately
so they may be returned for credit* to the manufacturer for a refund.
Provider Reimbursement
Alison’s Hope for Hearing will reimburse the provider for their professional time and
services. Reimbursement is as follows:



Comprehensive Audiological Exam: $75
Monaural Hearing Instrument Fitting: $200
Binaural Hearing Instrument Fitting: $300
*Reimbursement will still be made to provider, even if product is returned for credit.
Payment to provider will be paid by Alison’s Hope for Hearing within 45 days of receipt
of Request for Provider Reimbursement Form and signed proof of Receipt and
Acceptance of Amplification by the patient.
--------------------------------------------------------------------------------------------------------------------I have read the above information and would like to help Alison’s Hope for Hearing
further their mission by becoming a provider! I will forward to Alison’s Hope any
prospective patients that may benefit from your hearing aid program and would be
open to receiving referrals from Alison’s Hope should a qualified candidate need fitting
support in my area. I understand the expectations for being a provider and agree to the
reimbursement fees above:
Name of Provider: _______________________________________________________
Signature of Provider: ____________________________________________________
State License Number: _______________________________ Year Issued: ___________
Address: _______________________________________________________________
_______________________________________________________________
Phone: ___________________________ Fax:_________________________________
Email: _________________________________________________________________
Your personal information will be kept strictly confidential, and will not be sold or
published. It will only be used by Alison’s Hope for Hearing board members, and will be
guarded with same care and confidentiality as our own personal data.
Please submit to: Alison’s Hope for Hearing, PO Box 47834, Minneapolis, MN 55447