Get the free Cochlear Implant Evaluation Request Form - dhcs ca

Attachment 1 COCHLEAR IMPLANT EVALUATION REQUEST FORM To be completed by referring audiologist or physician CHILD NAME DATE OF BIRTH Type and degree of hearing loss (please enclose audio gram): Etiology

How to fill out cochlear implant evaluation request

How to fill out a cochlear implant evaluation request:

1. Begin by downloading or obtaining the official cochlear implant evaluation request form. This form is usually available on the website of the medical facility or hospital that performs cochlear implant evaluations.
2. Read the instructions carefully. The form may require you to provide personal details such as your name, contact information, and date of birth.
3. Fill in the sections that require information about your hearing history. This may include details about when you first experienced hearing loss, any previous hearing aids or assistive devices you have used, and any medical conditions related to your hearing loss.
4. Provide information about your current hearing abilities. You may need to describe the extent of your hearing loss, such as whether it affects both ears or just one. Include any relevant audiogram (hearing test) results if you have them.
5. Detail your communication preferences. Indicate whether you primarily rely on spoken language, sign language, or a combination of both. This helps the evaluation team understand your communication needs.
6. Explain why you are seeking a cochlear implant evaluation. You may want to describe the challenges you face with your current hearing abilities and how they impact your daily life.
7. If applicable, provide information about any insurance coverage you have. This may include the name of your insurance provider and your policy number.
8. Sign and date the form.
9. After completing the form, submit it to the designated department or clinic. You might need to send it through mail, email, fax, or an online submission portal. Follow the instructions provided by the facility.

Who needs a cochlear implant evaluation request:

1. Individuals with severe to profound hearing loss who have not obtained sufficient benefit from hearing aids may benefit from a cochlear implant evaluation.
2. People who experience difficulty understanding speech, especially in noisy environments, despite using the highest level of hearing aids recommended by their audiologist.
3. Those who have a medical condition or receive treatment that contraindicates the use of hearing aids.
4. Candidates who have realistic expectations and are motivated to undergo the evaluation and the potential cochlear implant surgery.
5. Individuals of various ages, including children and adults, who seek to improve their hearing abilities and overall quality of life.

It is important to consult with a healthcare professional or an audiologist specializing in cochlear implants to determine if you are a suitable candidate for a cochlear implant evaluation. They will guide you through the necessary steps and provide the appropriate resources.

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What is cochlear implant evaluation request?

The cochlear implant evaluation request is a formal request submitted to assess a patient's candidacy for a cochlear implant.

Who is required to file cochlear implant evaluation request?

Patients who are experiencing severe hearing loss and are potential candidates for a cochlear implant are required to file the evaluation request.

How to fill out cochlear implant evaluation request?

The evaluation request can be filled out by the patient's healthcare provider or audiologist, who will gather the necessary medical history and hearing test results.

What is the purpose of cochlear implant evaluation request?

The purpose of the evaluation request is to determine if a patient is a suitable candidate for a cochlear implant based on their medical history and hearing loss severity.

What information must be reported on cochlear implant evaluation request?

The evaluation request must include the patient's medical history, results of hearing tests, and any other relevant information regarding the patient's hearing loss.