{"id":201,"date":"2020-02-24T15:51:35","date_gmt":"2020-02-24T21:51:35","guid":{"rendered":"https:\/\/chsstl.fm1.dev\/about-us\/patient-forms\/"},"modified":"2024-12-02T10:04:11","modified_gmt":"2024-12-02T16:04:11","slug":"patient-forms","status":"publish","type":"page","link":"https:\/\/chsstl.org\/about-us\/resources\/patient-forms\/","title":{"rendered":"Patient Forms"},"content":{"rendered":"\n

Client Registration<\/h2>\n\n\n\n

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.<\/p>\n\n\n\n

Client Registration Form<\/a>Download<\/a><\/div>\n\n\n\n

Scholarship Application<\/h2>\n\n\n\n

This form is required for those applying for financial assistance through our scholarship program.<\/p>\n\n\n\n

Scholarship Application<\/a><\/p>\n\n\n\n\n

<\/div>\n\n\n\n

Red Card Assistance Program<\/h2>\n\n\n\n

This form is required for those applying for financial assistance through the Red Card Assistance program.<\/p>\n\n\n\n

Red Card Assistance<\/a><\/p>\n\n\n\n\n\n

<\/div>\n\n\n\n

Privacy Forms<\/h2>\n\n\n\n
Protected Health Information Notice<\/a>Download<\/a><\/div>\n\n\n\n

Client Surveys<\/h2>\n\n\n\n

Audiology Survey<\/a><\/p>\n\n\n\n

Speech-Language Survey<\/a>Download<\/a><\/div>\n\n\n\n

Case History Forms<\/h2>\n\n\n\n

Adult Hearing Evaluation (Audiology)<\/a><\/p>\n\n\n\n

Pediatric Hearing Evaluation (Audiology)<\/a><\/p>\n\n\n\n

Pediatric Speech Language Evaluation<\/a><\/p>\n\n\n\n

Cochlear Implant Evaluation<\/a><\/p>\n\n\n\n

Pediatric Auditory Processing Disorder<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"

Client Registration 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. Scholarship Application…<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":113,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_seopress_robots_primary_cat":"","_seopress_titles_title":"","_seopress_titles_desc":"","_seopress_robots_index":"","schema":"","fname":"","lname":"","position":"","credentials":"","email_address":"","placeID":"","no_match":false,"name":"","company":"","review":"","address":"","city":"","state":"","zip":"","lat":"","lng":"","phone1":"","phone2":"","fax":"","mon1":"","mon2":"","tue1":"","tue2":"","wed1":"","wed2":"","thu1":"","thu2":"","fri1":"","fri2":"","sat1":"","sat2":"","sun1":"","sun2":"","hours-note":"","footnotes":""},"service_tags":[],"_links":{"self":[{"href":"https:\/\/chsstl.org\/wp-json\/wp\/v2\/pages\/201"}],"collection":[{"href":"https:\/\/chsstl.org\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/chsstl.org\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/chsstl.org\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/chsstl.org\/wp-json\/wp\/v2\/comments?post=201"}],"version-history":[{"count":74,"href":"https:\/\/chsstl.org\/wp-json\/wp\/v2\/pages\/201\/revisions"}],"predecessor-version":[{"id":3483,"href":"https:\/\/chsstl.org\/wp-json\/wp\/v2\/pages\/201\/revisions\/3483"}],"up":[{"embeddable":true,"href":"https:\/\/chsstl.org\/wp-json\/wp\/v2\/pages\/113"}],"wp:attachment":[{"href":"https:\/\/chsstl.org\/wp-json\/wp\/v2\/media?parent=201"}],"wp:term":[{"taxonomy":"service_tags","embeddable":true,"href":"https:\/\/chsstl.org\/wp-json\/wp\/v2\/service_tags?post=201"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}