Physician'S Report Of History, Examination, And Recommendation For Hearing Aid Form
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1PHYSICIAN'S REPORT OF HISTORY, EXAMINATION,
AND RECOMMENDATION FOR HEARING AID
(To be filled out by physician only and sent along with TAR, Mc - 1449 report, and prescription to provider).
Completion of this form will expedite Medi-Cal Consultant's review required by Section 51319 of Title 22, California Administrative
Code.
1.
Name of Patient:________________________________
Medi-Cal ID#: __________________________________
Birth
2.
Age: _______
Sex: ________
Date: ______________
ENT Exam Date: ___________________ 20 ____
3.
Diagnosis: Medical (Otological)
Place of Exam: _______________________________________________________
4.
Patient has had a hearing loss:
AD [ ] AS [ ] AU [ ]
(Check applicable box(es))
Since __________________ Due To ___________________________________________________________________
5.
Has patient ever worn a hearing aid?
Yes [ ]
No [ ]
6.
Patient has worn a hearing aid for _________ years on the ________ ear.
7.
Tinnitus:
Yes [ ] No [ ]
If yes, Type __________ Ear __________
AD [ ] AS [ ] AU [ ]
8.
Other physical and / or MENTAL IMPAIRMENTS that would affect this patient's use of a hearing aid and ability to adapt to
its uses (Contraindications for an ear mold, general ability to manipulate and be responsible for a hearing aid).
9.
What medical and / or surgical treatment has been performed in the past relative to the hearing impairment?
10.
Does patient have any medically or surgically correctable conditions or one requiring further evaluation? If yes, describe.
11.
The audiological evaluation has been performed by me: __________________________ (Name), or a licensed audiologist
___________________________ (Name), or by personnel under my supervision ___________________________ (Name).
12.
This patient has had a complete examination of the ear, nose, and throat by me, and has the requisite psychological and
physical well being to successfully wear and care for a hearing aid.
Yes [ ]
No [ ]
13.
SIGNATURE: ___________________________________________ M.D. Print name and address below:
Otolaryngologist / Personal Physician
Name
Address
City / State / Zip
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