Hearing Education & Assistance by Rocky Mountain Sertomans
2125 E. La Salle St, L!2
"olorado S#rings, "$ %&'&'
()e HEARS $**ice is manned only on ()ursdays %+!& to 11+!& am.
HEARS "ell ,)one+ -.1'/ !525120
-Lea1e a Message on t)e "ell ,)one any time/
Dear Applicant:
Thank you for requesting an application for hearing aid assistance through Hearing Education &
Assistance by Rocky Mountain Sertomans
!n "#$$% HEARS &as launched to pro'ide hearing aids to lo&(income people &ho could not
other&ise afford them )his program ser'es adults and children &ho reside in El *aso +ounty HEARS is
mainly supported and funded by local SER),MA clubs -hen a used hearing aid is donated to the HEARS
program% hearing aid manufacturers e.tend credit used for repair of hearing aids /ou can find out more
about donating faulty hearing aid0s1 by calling 02"#1 345(4"56 )he HEARS +ommittee is proud to
announce that o'er 5477 hearing aids and other ser'ices ha'e been pro'ided at little or no cost to
qualifying clients through this program
)he follo&ing instructions &ill help you complete the application
WE REQUIRE: Proof of income for each applicant% and all persons included in your 8family si9e%: unless
a person is a dependant We require complete bank statements for the last nine months 0both
checking and sa'ings1. -e require proof of income to 'erify your true financial need% and &hat you &rite
in the financial section of this application !f you do not ha'e bank accounts% you must &rite a letter
detailing your reasons% and stating your monthly income /ou must sign and date the letter and have it
notarized ***YUR !PP"I#!$I% #!% %$ &E PR#E''E( WI$)U$ $)E'E***
Enter an* medical e+penses that *o, paid for completel* o,t of *o,r pocket- d,rin. the last /0
months 1We cannot incl,de co2pa*s and premi,ms3. )his may include receipts for medications%
'ision% dental% etc -e &ill deduct these figures from your household income to better represent your
ad;usted net income At this point the HEARS office &ill determine if you qualify for this program *lease
note that o'er #7< of all applicants qualify for free hearing test and free hearing aids -e apply your
annual ad;usted income to a go'ernment sliding scale 0Department of Health tables1 )he HEARS office
pays "77< of cost for hearing aids= ho&e'er% for those of you &ho do >,) qualify for "77< free hearing
aids *o, 4ill be re5,ired to pa* a co2pa* in addition to *o,r 607.77 application processin. fee
)he dollar amount of the co(pay is determined from go'ernment income tables and the HEARS office does
not ha'e control of the results
YUR !PP"I#!$I% 8U'$ &E 'I9%E(- (!$E(- !%( %$!RI:E( % $)E ;RE"E!'E< P!9E.
,nce you complete the application and pro'ide the necessary documents *o, can mail it to the address
abo'e -hen your application is processed you &ill be notified of the results by letter !f your application
is appro'ed you &ill be required to pay the nonrefundable processing fee of ?5777 After your enrollment
fee is recei'ed% you &ill be assigned to an audiologist in +olorado Springs /ou &ill be responsible for
making your appointment &ith the assigned audiologist =or $hose of *o, 4ho are re5,ired to pa* a
co2pa*% Yo, &ill be assigned to a HEARS audiologist &hen the ?5777 and co(pay are recei'ed in the
HEARS office

)earin. Ed,cation > !ssistance b* Rock* 8o,ntain 'ertomans
2125 E. La Salle St, L!2
"olorado S#rings, "$ %&'&'
()e HEARS $**ice is manned only on ()ursdays %+!& to 11+!& am.
HEARS "ell ,)one+ -.1'/ !525120
-Lea1e a Message on t)e "ell ,)one any time/
!PP"I#!$I% =R )E!RI%9 !I( !''I'$!%#E
P"E!'E RE!( $)RU9) !%( #8P"E$E !"" P!9E' (!$E: ????????
)o4 did *o, hear abo,t o,r pro.ram@ Referred b* 1%ame- r.anization- Phone %,mber3:

What are *o,r hearin. needs@ ???????????????????????????????????????????????
)ave *o, ever been thro,.h the )E!R' pro.ram @Yes c %o c
Yo,r 1!pplicantAs3 %ame: ?????????????????????????????????????????????????
(..&.: ??????????????? !.e: ???????????? 'e+: 8ale c =emale c
#o,nt* of Residence: U.'. #I$I:E%: Yes c %o c

#it*:??????????????????????????????????? 'tate: :ip #ode:
Yo,r E2mail: ?????????????????????????????
Primar* PhoneB: 1????3?????????????????? ther PhoneB: 1????3?????????
Emplo*er: Work PhoneB: 1????3?????????
Emer.enc* #ontact: $heir PhoneB: 1????3??????????
Relationship: 1(a,.hter- &rother- =riend- etc.3
)ave *o, been to an a,diolo.ist or hearin. clinic for eval,ation@ Yes c %o c
If *es- name????????????????????????????????????????????

YU 8U'$ PRCI(E #8P"E$E PR= = I%#8E
R $)I' !PP"I#!$I% #!% %$ &E PR#E''E(
We re5,ire nine months of bank statements to verif* *o,r financial need. We also
re5,ire most recent 'ocial 'ec,rit* 'tatement of &enefits if available andDor most
recent W0s - or pa* statements.
If you do not have bank accounts, you must write a letter to this effect, and state your monthly
income, then sign it and have it notarized. We also require other proof of income 0ie your
Social Security statement% paycheck stubs% retirement statement% -5s etc1
***YUR !PP"I#!$I% #!% %$ &E PR#E''E( WI$)U$ $)E'E***
=amil* 'ize ??????????1People livin. in the ho,sehold3
!pplicantAs 8onthl* Income 6 'o,rce:
1i.e. emplo*ment- 'ocial
'ec,rit*- ''I- pension-
retirement- etc3
!pplicantAs !dditional 8onthl* Income 6 'o,rce: ????????
1i.e. emplo*ment- 'ocial
'ec,rit*- ''I- pension-
retirement- etc3
ther =amil* 8embersA 8onthl* Income 6 'o,rce:
1i.e. emplo*ment- 'ocial
'ec,rit*- ''I- pension-
retirement- etc
$$!" 8%$)"Y )U'E)"( I%#8E: 6
Yearl* 8edical E+penses 6 *!ttach copies of receipts
1E+cl,din. co2pa*s and Ins,rance premi,ms3 for the past /0 months:
Prescriptions- dental e+penses-
vision e+penses- etc.
=or ffice Use nl*
)otal /early !ncome 0income less
medical e.penses1: ??????????????????????????????????????????????????
*ercent Discount Assigned:
*rocessing Staff Appro'al:
! certify that the information ! ha'e gi'en is true and accurate to the best of my kno&ledge @urther% !
&ill make a'ailable to the appropriate pro'ider information regarding my medical insurance 0Medicaid%
Medicare% or pri'ate insurance1 &hich &ill be used to bill for the E>) ser'ices ! understand that ! am
responsible for E>) charges &hich are not co'ered by the HEARS program nor my insurance ! &ill be
informed of the percentage co'ered by the HEARS program prior to the charges being incurred
! understand that this application is made so that the HEARS program can determine my eligibility for
the uncompensated ser'ices 0under the Hill(Aurton Act1 based on the established criteria on file !f
any information ! ha'e pro'ided is found to be fraudulent% ! understand that the HEARS +ommittee
may re(e'aluate my financial status and take &hate'er action is deemed necessary
! authori9e the HEARS program to collect and release information related to my hearing problem from
any past or current pro'ider
! hereby release SER),MA% and the HEARS program from any liability in furnishing needed
! ha'e applied for funding assistance andBor ser'ices through the HEARS program% &hich is a
collaborati'e program of the Southern +olorado SER),MA +lubs
All ser'ices &ill be performed by professional 'endors and HEARS pro'iders ! agree to hold harmless
all those associated &ith the HEARS program from any claims arising through the ser'ices andBor
equipment pro'ided by this program

ApplicantCs Signature 0or parentBguardian1 Date
18U'$ &E 'I9%E( and dated I% $)E PRE'E%#E = ! %$!RY3
$he information on this application and the above release has been s,bscribed
and affirmed- or s4orn to before me in the co,nt* of
'tate of #olorado- this da* of ?????????? 07 .

%otar* 'i.nat,re #ommission E+piration (ate

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