{"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":"2024-03-29T12:40:23","modified_gmt":"2024-03-29T17:40:23","slug":"patient-forms","status":"publish","type":"page","link":"https:\/\/chsstl.org\/about-us\/resources\/patient-forms\/","title":{"rendered":"Patient Forms"},"content":{"rendered":"\n<h2 class=\"wp-block-heading\">Client Registration<\/h2>\n\n\n\n<p>This new patient form includes general contact information, insurance details and emergency contact numbers. The form grants the Center for Hearing &amp; Speech permission to release any information necessary to process claims related to your care and allows the Center for Hearing &amp; Speech to apply for benefits on your behalf.<\/p>\n\n\n\n<div class=\"wp-block-file\"><a id=\"wp-block-file--media-b24bf0e2-f48f-4ea3-8d47-86e33ff77b1c\" href=\"https:\/\/chsstl.org\/wp-content\/uploads\/2020\/10\/csh_client_registration_v4.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">Client Registration Form<\/a><a href=\"https:\/\/chsstl.org\/wp-content\/uploads\/2020\/10\/csh_client_registration_v4.pdf\" class=\"wp-block-file__button wp-element-button\" download aria-describedby=\"wp-block-file--media-b24bf0e2-f48f-4ea3-8d47-86e33ff77b1c\">Download<\/a><\/div>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"scholarship\">Scholarship Application<\/h2>\n\n\n\n<p>This form is required for those applying for financial assistance through our scholarship program.<\/p>\n\n\n\n<p>We apologize but the current application window is closed. Please check back on June 1st for the next opportunity.<\/p>\n\n\n\n<div class=\"application-divider\"><\/div>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"red-card\">Red Card Assistance Program<\/h2>\n\n\n\n<p>This form is required for those applying for financial assistance through the Red Card Assistance program.<\/p>\n\n\n\n<p>We apologize but the current application window is closed. Please check back on June 1st for the next opportunity.<\/p>\n\n\n\n<div class=\"application-divider\"><\/div>\n\n\n\n<h2 class=\"wp-block-heading\">Privacy Forms<\/h2>\n\n\n\n<div class=\"wp-block-file\"><a id=\"wp-block-file--media-15fa58d6-cd9a-43f3-a975-3fceae64ddf4\" href=\"https:\/\/chsstl.org\/wp-content\/uploads\/2020\/04\/6a5152_20698d013fe7482b9b2533bfa58d669f.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">Protected Health Information Notice<\/a><a href=\"https:\/\/chsstl.org\/wp-content\/uploads\/2020\/04\/6a5152_20698d013fe7482b9b2533bfa58d669f.pdf\" class=\"wp-block-file__button wp-element-button\" download aria-describedby=\"wp-block-file--media-15fa58d6-cd9a-43f3-a975-3fceae64ddf4\">Download<\/a><\/div>\n\n\n\n<h2 class=\"wp-block-heading\">Client Surveys<\/h2>\n\n\n\n<p><a href=\"https:\/\/www.surveymonkey.com\/r\/7XNCG23\" target=\"_blank\" rel=\"noreferrer noopener\">Audiology Survey<\/a><\/p>\n\n\n\n<div class=\"wp-block-file\"><a id=\"wp-block-file--media-b57452ab-463b-44fe-ba03-ad976d0f2304\" href=\"https:\/\/chsstl.org\/wp-content\/uploads\/2020\/04\/6a5152_fd2390d7189046ba9147e59f5b2113e7.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">Speech-Language Survey<\/a><a href=\"https:\/\/chsstl.org\/wp-content\/uploads\/2020\/04\/6a5152_fd2390d7189046ba9147e59f5b2113e7.pdf\" class=\"wp-block-file__button wp-element-button\" download aria-describedby=\"wp-block-file--media-b57452ab-463b-44fe-ba03-ad976d0f2304\">Download<\/a><\/div>\n\n\n\n<h2 class=\"wp-block-heading\">Case History Forms<\/h2>\n\n\n\n<p><a href=\"https:\/\/my.lobbie.com\/public\/forms\/c09f595e-76cb-45cf-9a37-5ed6e83d469a\/387\/9198bbe2-94bd-4e95-a2b7-3a3cc507c25c\" target=\"_blank\" rel=\"noreferrer noopener\">Adult Hearing Evaluation (Audiology)<\/a><\/p>\n\n\n\n<p><a href=\"https:\/\/my.lobbie.com\/public\/forms\/c09f595e-76cb-45cf-9a37-5ed6e83d469a\/387\/2e6e04a5-677c-4533-a79b-aa691935d013\" target=\"_blank\" rel=\"noreferrer noopener\">Pediatric Hearing Evaluation (Audiology)<\/a><\/p>\n\n\n\n<p><a href=\"https:\/\/my.lobbie.com\/public\/forms\/c09f595e-76cb-45cf-9a37-5ed6e83d469a\/387\/dc203f1e-8717-41a0-b86e-92565625c8e5\" target=\"_blank\" rel=\"noreferrer noopener\">Pediatric Speech Language Evaluation<\/a><\/p>\n\n\n\n<p><a href=\"https:\/\/my.lobbie.com\/public\/forms\/c09f595e-76cb-45cf-9a37-5ed6e83d469a\/387\/6f6a7e21-0157-465c-9a1b-8722f0d96de7\" target=\"_blank\" rel=\"noreferrer noopener\">Cochlear Implant Evaluation<\/a><\/p>\n\n\n\n<p><a href=\"https:\/\/my.lobbie.com\/public\/forms\/c09f595e-76cb-45cf-9a37-5ed6e83d469a\/387\/142e8f79-96b6-4954-ad66-d3c5447136c4\" target=\"_blank\" rel=\"noreferrer noopener\">Pediatric Auditory Processing Disorder<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Client Registration This new patient form includes general contact information, insurance details and emergency contact numbers. The form grants the Center for Hearing &amp; Speech permission to release any information necessary to process claims related to your care and allows the Center for Hearing &amp; Speech to apply for benefits on your behalf. Scholarship Application&#8230;<\/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":42,"href":"https:\/\/chsstl.org\/wp-json\/wp\/v2\/pages\/201\/revisions"}],"predecessor-version":[{"id":3236,"href":"https:\/\/chsstl.org\/wp-json\/wp\/v2\/pages\/201\/revisions\/3236"}],"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}]}}