APPLICATION PROCESS

Lend An Ear Outreach, Inc. (hereafter “Lend An Ear”) is a 501c3 non-profit organization to help lower income individuals with hearing loss obtain professional services and hearing aids.

DONATED HEARING AIDS

A. The hearing aids will be collected by mail or by being retrieved via volunteers at one of the area drop off locations. Once obtained, the hearing aids will be brought to a designated location to be logged in and inventoried on a master list.

B. The hearing aids will be made available to Dr. Jane Burns, our Senior Audiologist, or other volunteer Audiologists who are assisting Lend An Ear. The Audiologist will determine what type of hearing aid from the master list is required for a particular patient once an application has been approved by the Lend An Ear Committee.

C. If the collected hearing aids are deemed re-usable, they will eventually be sent to a laboratory to be recast and returned to the Audiologist who requested the hearing aid(s) for use for a particular application.

D. If the collected hearing aid is not deemed re-usable, they will be donated to the laboratory for a donation toward future hearing aid re-casting.

LEND AN EAR APPLICATION APPROVAL PROCESS

A. Applications will be handled on a first come, first serve basis by date and time of the submission. Applicants will be acquired through various sources, including but not limited to the Lend An Ear website, doctor referrals, word of mouth, telephone requests and e-mails.

B. Once an application is received by Lend An Ear, it will be logged in, reviewed and approved or rejected based on pre-set criteria.

C. If an application is approved, that patient will be assigned to a Lend An Ear volunteer Audiologist or a hearing instrument specialist and the applicant will be contacted by a representative to schedule an appointment. The Audiologist will be selected based on availability and the location of the applicant.

D. If an application is rejected to receive hearing aids at NO cost, the applicant will be informed of other options of services that may be available within Lend An Ear criteria for reduced cost hearing aids.

AUDIOLOGIST RESPONSIBILITIES

A. Once the applicant has been assigned, the Audiologist will perform a physical examination and evaluation to determine if he/she will be able to receive re-cased hearing aids.

B. If the hearing aid required is not available in our inventory to fit a particular applicant, Lend An Ear or the Audiologist will work with other foundations who provide hearing aids at the lowest cost available, not to exceed $400.00 for two. Lend An Ear will provide the medical examination and fitting at Lend An Ear’s cost.

C. Final Steps:a. If an applicant can be helped by resources presently available by Lend An Ear,

the applicant will progress as set forth above.b. If an applicant requires the hearing aids to be re-cased, there will be a nominal

fee of approximately $100.00 per hearing aid, to be paid by the Lend An Ear or the applicant based on Lend An Ear’s income criteria.

NOTE: Medical evaluations and hearing aids provided by Lend An Ear Foundation are based on availability of funds and hearing aids.

“Compassion You Can Hear”

ApplicationFor Hearing Aid

The gift of hearing should be available to everyone in need. Filling the need to acquire a hearing aid despite someone’s means is the

philosophy of Lend An Ear Outreach.

“He who has ears to hear, let him hear” Mark 4:9

We strive to help people of all ages reconnect with their community and loved ones through the gift of hearing. We exist to give all people

with limited means the ability to obtain a hearing aid.

Our mission, in part, is to promote personal safety for children and adults by providing education pertaining to hearing loss and its

ramifications.

APPLICATIONPlease type or print clearly

A $25.00 NON REFUNDABLE APPLICATION FEE MUST ACCOMPANY THIS APPLICATIONAn applicant may receive one or two refurbished hearing aid(s).

PERSONAL INFORMATIONNAME ________________________________________________ PHONE ___________________________

ADDRESS______________________________________________ STATE _______________ ZIP ____________

DATE OF BIRTH __________________________ SOCIAL SECURITY NO ______________________________

Male ( ) Female ( ) No. of Adults in household ____________ No. of Children in household __________

INSURANCE INFORMATIONMedicare I.D. No. ______________________________ **Medicaid I.D. No.____________________________

Health Insurance Co. ______________________________________ Phone ___________________________

**IF MEDICAID, NO FURTHER FINANCIAL INFO IS NECESSARY**

INCOMEApplicant’s Income $_______________________ Monthly ____ Semi-Monthly _____Weekly _____Biweekly_____

Other Household Member’s $ ________________ Monthly ____ Semi-Monthly _____Weekly _____Biweekly_____

Other Sources of Income Expenses

Social Security $_______________per mo. Rent/Mortgage $_______________per mo.

SSI $_______________per mo. Utilities $_______________per mo.

Retirement $_______________per mo. Insurance $_______________per mo.

Disability $_______________per mo. Medical $_______________per mo.

Food Stamps $_______________per mo. Medications $_______________per mo.

Other $_______________per mo. Loans(revolving, etc) $_______________per mo.

Total Monthly Income $_____________________ Total Monthly Expenses $____________________

***SUPPLY COPIES OF RENT, ALL UTILITIES AND OTHER EXPENSES CLAIMEDALONG WITH W2 FORM OR OTHER PROOF OF INCOME***

This application is for the use and benefit of those who do not have adequate income or resources to obtain a hearing aid.

I hereby authorize Lend An Ear Outreach, Inc., its duly authorized agents and representatives, to make such reasonable investigations as deemed sufficient in acting upon this application and such corporation, its agents or representatives, from any liability for such investigations. I certify that the foregoing statements and all information furnished by me to Lend An Ear in writing are true and correct.

Signature ______________________________________________ Date _____________________________

Comments: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

For Completion by LEND AN EAR OUTREACH, INC.

Date Received _____________________ Date forwarded to LAEO Coordinator ______________________

Interview Date _________________________ Referred by _______________________________________

Interviewed by ___________________________________ Phone No ____________________________

Approved by _____________________________________ Date ________________________________

SEND COMPLETED APPLICATIONS TO:

LEND AN EAR OUTREACH, INC1000 Vicars Landing Way

Ponte Vedra Beach, Fl 32082Lendanear@vicarslanding.comwww.lendanearoutreach.org

Medical evaluations and hearing aids provided by Lend An Ear Outreach, Inc. are based on availability of funds and hearing aids.

HOW TO COMPLETE THE LEND AN EAR OUTREACH, INC. APPLICATION

1. Read the application completely2. Complete all questions and date and sign the application. The applicant’s signature is

required on page 2 of the application.3. Gather income information for all those in the household and attach this information to

the application. Note: If you have a Medicaid number, you do not need to provide the income information.

4. Gather copies of bank statements – Statements are needed for each account belonging to each individual in the household (most recent six months). A copy of each page of each statement is required.

5. Gather all of the other necessary support documentation as outlined on Page 1.6. Include a money order or check in the amount of $25.00 representing the non-

refundable application fee.7. DO NOT SEND ORIGINAL DOCUMENTS – THEY WILL NOT BE RETURNED TO YOU.8. Mail all material to:

Lend An Ear Outreach, Inc.1000 Vicars Landing Way

Ponte Vedra Beach, Fl 32082

Once you have mailed the application to Lend An Ear, please wait at least 5 weeks before making a call for a status check of your application.

*Additional information may be needed after initial review of the application.**Lend An Ear Outreach, Inc. reserves the right to change criteria at any time without prior

written notice.

HEARING AID COST GUIDELINE

SCHEDULE 1

MEDICAID ELIGIBLE $13,000 TO $19,000 $19,001 TO $38, 000

100% OF HEARING AIDS APPLICANT PAYS $50.00 per APPICANT PAYS $200.00PAID BY LEND AN EAR hearing aid/LEND AN EAR

Pays $50.00 per hearing aid

SCHEDULE 2

For those Applicants whose income is over $38,000, Lend An Ear may be able to work with other foundations to help you with an alternative provider.

1000 Vicars Landing WayPonte Vedra Beach, FL 32082

Phone: 904-241-HEAR or 904-241-4327Fax: 904-285-1384

E-mail: Lendanear@vicarslanding.com

Consent to Release of Information

Name: ___________________________________________ Date:_________________________

Address: _____________________________________________________________

_____________________________________________________________

Phone No. __________________________________

Acceptance of hearing aids and services of Lend An Ear Outreach, Inc. constitutes permission to use applicant’s name and photograph for promotional purposes, unless prohibited by law.

This consent (unless expressly revoked earlier) expires twenty-four (24) months from the date indicated below.

_______________________________________ Print Name:

_______________________________________ Date:_________________________Signature of Applicant

LEND AN EAR OUTREACH, INC.

By:____________________________________ Date:__________________________