Hearing Aid Request Form

Partner audiologists can use this form to request hearing aids for their patients. Audiologists must be registered with the Frink Foundation before requesting hearing aids.

Requests will be processed within five business days. Requests will be fulfilled in the order which they are received.

Please do not provide any protected health information or other identifiable information about your patients. The Frink Foundation does not maintain any patient information in its database and thus should not be provided with any HIPAA sensitive patient information.

Provider Name

First Name

Last Name

Preferred Hearing Aid Type

If RIC or slim tube BTE, what wire or tube length?

Preferred Brand (we will do our best to meet your request based on donated stock on hand)

Preferred Hearing Aid Color (we will do our best to match based on stock on hand)

Other Relevant Patient Information (dexterity issues, technology needs, etc)

I understand there is a $25 shipping fee for any devices received from the Frink Foundation. I understand I will receive a monthly invoice for the accrued fees. I understand that I, the partner audiologist, am responsible for paying this fee, but that I may pass the cost on to the patient at my discretion.

Yes

I certify that I am a registered partner audiologist with the Frink Foundation at the time of submitting this form.

Yes

I certify that I will fit any donated device a receive through the Frink Foundation in accordance with the Foundation's guidelines.

Yes

I certify that the patient being fit with these devices meets the Foundation's criteria for donated devices. I understand it is my duty to ensure patients meet financial and other requirements as part of my Foundation partnership.

Yes

Hearing Aid Request Form

Norm and JoAnn Frink Hearing Foundation