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107 BRANDON ROAD, STARKVILLE MS 39759 PHONE (662)6153771, FAX (662)6153775CONSENT TO TREAT I hereby authorize Joshua T. Black, M.D., Mercedes Terrell, M.D., Ben Sanford, M.D., Audrey Schilling, N.P.,
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Start by obtaining the combined severe-to-profound hearing form from a healthcare provider or audiologist.
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Fill out the personal information section such as name, address, and contact details.
03
Provide details about your hearing loss history, including when it started and any treatments or devices you have used in the past.
04
Answer the questionnaire regarding your hearing abilities in different environments and with various types of sounds.
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Make sure to sign and date the form before submitting it to the appropriate healthcare provider or organization.

Who needs combined severe-to-profound hearing and?

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Individuals who have been diagnosed with severe-to-profound hearing loss may need to fill out a combined severe-to-profound hearing form to provide detailed information about their condition.
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Combined severe-to-profound hearing refers to a significant level of hearing loss that impacts an individual's ability to hear sounds at normal thresholds, often necessitating the use of hearing aids or other assistive devices.
Individuals identified with combined severe-to-profound hearing, typically assessed by a qualified audiologist or medical professional, are required to file the appropriate documentation to access services or benefits.
To fill out combined severe-to-profound hearing documentation, one must provide personal information, details of the hearing assessment, and any recommendations made by healthcare professionals regarding hearing aids or support services.
The purpose of combined severe-to-profound hearing documentation is to assess an individual's degree of hearing loss and facilitate access to necessary services, support, and accommodations.
Information that must be reported includes the individual's personal details, results from hearing assessments, date of evaluation, and any treatment or intervention plans suggested by professionals.
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