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OtsegoNorthernCatskillsBOCES
ItinerantandRelatedServices
Kimberley. Currant, Supervisor
OtsegoAreaOccupationalCenter
1914CtyRte35Milford,NY13807
6072867715ext2608/2701
6072869603FaxHEARINGIMPAIREDEVALUATIONREFERRALFORM
StudentInformationDate:
StudentName:
Gender:
DOB:
Grade:
Parents:
Address:
Phone:(home)Phone:(work)SchoolDistrict:
SchoolAttending:
Principal:
Teacher:
Referred:
ReasonforReferral:Page1of3Updated12/2019HEARINGIMPAIREDEVALUAT
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How to fill out hearing impaired referral form
How to fill out hearing impaired referral form
01
Step 1: Start by reading and understanding the instructions provided with the hearing impaired referral form.
02
Step 2: Obtain all the necessary information and documents required for filling out the form, such as the patient's personal details, medical history, and any relevant test reports.
03
Step 3: Fill in the patient's personal details accurately, including full name, date of birth, address, contact information, and insurance details if applicable.
04
Step 4: Provide relevant medical information, including the type and degree of hearing impairment, any previous treatments or interventions, and any additional medical conditions.
05
Step 5: If required, provide information about the referring healthcare professional, including their name, contact information, and any supporting documentation.
06
Step 6: Review the completed form for accuracy and ensure all required sections are filled out correctly.
07
Step 7: Sign and date the form as necessary, and make a copy for your records if required.
08
Step 8: Submit the filled-out hearing impaired referral form to the relevant healthcare provider or organization as instructed.
Who needs hearing impaired referral form?
01
The hearing impaired referral form is typically required by individuals who are experiencing hearing problems and wish to seek further evaluation, diagnosis, or treatment.
02
It may also be required by healthcare professionals or organizations who need to refer patients with hearing impairments to specialists or specialized services.
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What is hearing impaired referral form?
The hearing impaired referral form is a document used to refer individuals who are suspected of having a hearing impairment to the appropriate resources for evaluation and assistance.
Who is required to file hearing impaired referral form?
Any individual or organization who suspects someone of having a hearing impairment is required to file a hearing impaired referral form.
How to fill out hearing impaired referral form?
To fill out a hearing impaired referral form, one must provide detailed information about the individual suspected of having a hearing impairment, as well as contact information for the referrer.
What is the purpose of hearing impaired referral form?
The purpose of the hearing impaired referral form is to ensure that individuals who may have a hearing impairment receive the appropriate evaluation and assistance.
What information must be reported on hearing impaired referral form?
The information reported on a hearing impaired referral form typically includes the individual's name, age, address, symptoms, and any relevant medical history.
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