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Tennessee Department of Health Newborn Screening Follow Up Program 1st Floor, R.S. Gas Building 630 Hart Lane, Nashville, Tennessee 37243 Phone (855) 2021357 Fax (615) 5328555** NOTE: Hearing results

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How to fill out hearing screen only form

01

Obtain the hearing screen only form from the appropriate healthcare provider or facility.

02

Fill out all personal information requested on the form, including name, date of birth, address, and contact information.

03

Provide information about any previous hearing screenings or testing that has been done.

04

Indicate any concerns or symptoms related to hearing loss that you may have experienced.

05

Sign and date the form to certify that the information provided is accurate.

Who needs hearing screen only form?

01

Individuals who are required to undergo a hearing screening as part of a medical evaluation or assessment.

02

Those who have concerns about their hearing and wish to have a baseline screening done.

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What is hearing screen only form?

Hearing screen only form is a form used to report the results of a hearing screening test.

Who is required to file hearing screen only form?

All individuals who have undergone a hearing screening test are required to file a hearing screen only form.

How to fill out hearing screen only form?

To fill out a hearing screen only form, you need to provide information about the individual who underwent the screening test and the results of the test.

What is the purpose of hearing screen only form?

The purpose of the hearing screen only form is to ensure that individuals who have undergone a hearing screening test receive appropriate follow-up care if needed.

What information must be reported on hearing screen only form?

The hearing screen only form must report the name of the individual, the date of the screening test, the results of the test, and any recommended follow-up care.

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