Newborn Hearing Screening Program Diagnostic Evaluation
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1
2NEWBORN HEARING SCREENING PROGRAM
DIAGNOSTIC EVALUATION
This prior approval is limited to outpatient examinations and/or audiological evaluations needed to confirm a diagnosis suspected on the
basis of an abnormal newborn hearing screening test. It is to be used solely for those infants referred by Public Health’s Newborn
Hearing Screening Program.
To be completed by Parent/Guardian: (instructions on reverse side of form)
1.
Child’s Name
2.
Birthdate
3. Sex M
F
4.
Parent/Guardian Name
5.
SS#
(Parent/Guardian)
6.
Address
(Street)
(City)
(County)
(State/Zip)
7.
Daytime Telephone
(
)
Work
Home
My Child:
Parent/Residency/Citizenship:
8.
Lives in Illinois?
Yes
No
Lives in Illinois?
Yes
No
Has private insurance benefits?
Yes
No
Is a citizen of US?
Yes
No
Has All Kids/Medicaid benefits?
Yes
No
I request assistance from Specialized Care for Children for my child’s special diagnostic evaluation.
I understand there will be no direct cost to me for this evaluation.
If I have medical insurance or All Kids/Medicaid benefits which cover my child, those benefits must be used.
I understand that if additional assistance is needed from Specialized Care for Children following this evaluation, I must submit a
separate application.
I authorize Specialized Care for Children to provide a copy of the necessary data to the Illinois Department of Public Health for
Newborn Hearing Screening Program follow-up/tracking purposes.
Signature of Parent/Guardian
Date
To be completed by Evaluator: (instructions on reverse side of form)
9.
Referring Physician/Audiologist
10. Referral Date
11. Evaluating Hospital/Clinic
12. Approved Audiologist
13. Appointment Date
DIAGNOSTIC EVALUATION REPORT (add pages if necessary)
14. Relevant Findings (Include frequencies tested and decibels):
15. Diagnosis:
16. Recommendations:
17. Date of Evaluation(s)
18.
Signature of Approved Audiologist
19. Send this form no later than 30 days from the date of service to:
20. Send billing to:
Division of Specialized Care for Children
Regional Office servicing the child’s home community. If unknown, send to
Claims Services
office closest to child’s home community. (See reverse side for listing.)
3135 Old Jacksonville Road
Bills may be denied if this referral is not received in time.
Springfield, IL 62704-6488
1-877-791-5170
03.45 (Rev. 11/15) The University of Illinois at Chicago
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