This new patient form includes general contact information, insurance details and emergency contact numbers. The form grants the Center for Hearing & Speech permission to release any information necessary to process claims related to your care and allows the Center for Hearing & Speech to apply for benefits on your behalf.
This form is required for those applying for financial assistance through our scholarship program.
Red Card Assistance Program
This form is required for those applying for financial assistance through the Red Care Assistance program.
Adult Case History Form
Please download and fill out the attached form prior to your visit.