Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Telecommunications relay service wikipedia , lookup
Evolution of mammalian auditory ossicles wikipedia , lookup
Lip reading wikipedia , lookup
Hearing loss wikipedia , lookup
Hearing aid wikipedia , lookup
Noise-induced hearing loss wikipedia , lookup
Sensorineural hearing loss wikipedia , lookup
Audiology and hearing health professionals in developed and developing countries wikipedia , lookup
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