New Jersey Department of Health

Special Child Health and Early Intervention Services

PO Box 364

Trenton, NJ 08625-0364

REQUEST FOR HEARING AIDS

Name, Last	First	Middle

Hospital or Facility Requesting Services

Address

Address

City	County	Zip Code

City	County	Zip Code

Telephone No. (Incl. Area Code)

Date of Birth

Telephone No. (Incl. Area Code)

The family agrees to $	family financial participation (see Guidelines).
Significant History

Describe Communication Status

Habilitative/Rehabilitative Plan and Recommendations

Hearing Aid Recommendation (Specify type, mold, telecoil)

Right Ear:

Left Ear:	Audiologist must notify dispenser of referral and direct that estimate of cost be sent to SCHEIS

Hearing Aid Dispenser to Whom Child is Referred:

Telephone No.:
Pure Tone Audiometry	NOTE: For this request to be processed, the following must be either on file at SCHEIS or submitted to SCHEIS:

Registration (SCH‑0)

Socio‑Economic Form (CH‑9)

Income Verification
Legend

ASHA ‑ 1974

AC	R	L

Unmasked	o	x

Masked	Δ	(

No Response	(	(

BC

Unmasked	<	>

Masked	[	]

No Response	(	(

Soundfield	S

R	L

SRT	____	____

Discrim.at

_____ SL	____	____

ANSI 1969	Hz 250 500 1K 2K 4K 6K 8K
0

10

20

30

40

50

60

70

80

90

100

110
Aural Acoustic – Immittance

Tympanometry

Right Ear:	Left Ear:

Reflex	Right Ear Stimulated
500	1KHz	2KHz	4KHz
Left Ear Stimulated
dB
500	1KHz	2KHz	4KHz
Pre and Post Amplification Data for Recommended Aid (Use objective measurements.)

Stimuli	Unaided	Aided

FOR STATE USE ONLY
Signature of Physician	Date	Signature of Audiologist (CCC‑A)
SCH-13	Distribution: Original and 1 Copy - SCHEIS

JUL 12	Copy - Center Copy

SCH-13, Request for Hearing Aids

SCH-13, SCHEIS, hearing aids, request, special child health, SCH

ewhite

2001-07-06

NJDOH