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    Personal Information:
















    Medical Information:



    YesNo

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    YesNo

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    I hereby authorize the above named Audiologist/Physician to release any information necessary to process this application.

    Household Income and Asset Declaration:

    Please attach a copy of pages 1 and 2 of your most recent IRS Tax Return and supporting documentation in a zip file for all items marked YES (√) with this application.


    YesNo




    YesNo



    YesNo



    YesNo




    YesNo



    YesNo



    Total value of all savings, checking, CD’s, money market accounts, etc. (Send statement Copy)








    Interest from savings, checking, CD’s, money market accounts, etc.


    YesNo



    Total value of all stocks, bonds, etc.







    YesNo




    YesNo




    YesNo




    YesNo




    YesNo




    YesNo



    YesNo



    YesNo




    YesNo



    I fully understand that the Dr. Ann Stadelmaier Hearing Aid Fund services are limited to persons unable to pay, or who do not receive assistance from other sources. In consideration for such services, I hereby release and discharge all persons rendering such service from any claims that might arise from services or assistance provided. I understand that all information provided will be treated confidentially in accordance with HIPAA regulations. I give consent to release the minimum necessary information to additional sources that may assist in the funding of this hearing aid.