Cochlear Implant Awareness Foundation

Are you a US or Canadian Citizen? US Canadian

Do you have insurance of any kind, Medicare, or Medicaid? Yes No

If Yes, what kind?

Have you been awarded previous assistance from The Cochlear Implant Awareness Foundation (CIAF)? Yes No

Have you received previous assistance from any other organization? Yes No

If you have already been awarded, or have sought cochlear implant equipment from another organization (such as the CNI), and are applying for financial assistance for surgical, hospital, or other CI related fees only, please do not apply. Your application will not be accepted.

Who referrred you to CIAF?

I Agree to the following: I understand only complete applications will be reviewed If my entire application is not complete CIAF will not review my application I understand CIAF is a private foundation and is not affliated with Cochlear Corporation - Advanced Bionics - Med-El - or any other organization I understand CIAF can refuse/deny my application and request for assistance for any reason I understand CIAF does its very best to help all recipients but cannot help every applicant as CIAF has limited amounts of equipment available to recipients I understand if CIAF accepts my application I am responsible for paying the application - administrative - and shipping/handling fees associated with my application and requested equipment needs I may be responsible for addition fees not stated below if my equipment needs change from this application I understand I will receive an e-mail invoice from CIAF that outlines the various fees I will be responsible for if my application is accepted by CIAF and my doctor If my application is accepted by CIAF I must pay the associated fees via Paypal in order for application to be processed and shipped to me and/or my doctor Please note all fees are outlined below and will also be outlined on email invoice All fees must be paid via Paypal by credit or debit card by the applicant/patient before any equipment will shipped I understand if I do not pay the associated fees I will not receive the equipment I understand CIAF provides NO monetary assistance whatsoever nor any funding for cochlear implant surgery or associated fees related to cochlear implants/cochlear implant surgery/cochlear implant services/etc I understand my request for equipment must be verified by my doctor or audiologist. As such I give CIAF and my health care providers consent to speak about my cochlear implant equipment needs Processors or programable devices will shipped to the patients/applicant's doctor or audiologist. Other equipment may be sent to directly patient If CIAF ships equipment to more than one address - additional shipping fees will assessed and must be paid by the applicant If CIAF has the requested equipment in the application CIAF will confirm my needs the with my health care provider. Once CIAF contacts my doctor/health care provider my doctor/my health care provider must verify my equipment needs CIAF will not send fulfill any applications without the consent of the patient/applicant's doctor Once my doctor/health care provider verifies my needs with CIAF - CIAF will send me invoice outlining the application/administrative fees/shipping/handling I must pay this fee within 48 hours. If I do not pay this fee within 48 hours my application will be deemed ineligible and the requested equipment will not shipped If this application is selected for assistance the resulting transaction and any claim or dispute arising out of such transaction shall be governed by the laws of the state of Illinois.

PLEASE CHOOSE ONE: Child Adult Senior Veteran

RECIPIENT APPLICATION

I understand that if approved for equipment, I will be responsible for all application, administrative, processing, and shipping and handling fees. Yes No

REQUIRED PERSONAL STATEMENT, PHOTO, AND PHOTO RELEASE

CIAF is a 501(c)(3) non-profit organization which relies primarily on donations to help us to provide cochlear implant equipment to qualified applicants without cost to the family or individual in need. As part of our program, we require applicants to complete a personal statement as to how the cochlear implant will improve their life. We also require a photo of each applicant to accompany his/her application. While the personal statement gives a voice to our mission, photographs provide a visual connection for our supporters and helps bring an applicant’s story to life. Both components greatly assist us in promoting our mission to help more people hear! If the applicant is between 13 and 18 years of age, both the applicant and a guardian should write separate statements. If the applicant is less then 13 years of age, a statement from a guardian is sufficient.

PLEASE UPLOAD A PHOTO

Read and sign the Photo Release. Without the personal statement or photograph, we will be unable to process your application. I agree No I don't agree

I authorize the Cochlear Implant Awareness Foundation, hereafter referred to as “CIAF” to publish photographs of me, and my name and likeness, for the use in CIAF print and online marketing materials as well as other CIAF publications. I hereby release and hold harmless CIAF from any reasonable expectation of privacy or confidentiality associated with images specified above. I further acknowledge that my participation is voluntary and that I will not receive financial compensation of any type associated with the taking or publication of these photographs or participation in company marketing materials or other CIAF publications. I acknowledge and agree that publication of said photos confers no rights of ownership or royalties whatsoever. I hereby release CIAF, its contractors, its employees, and any third parties involved in the creation or publication of marketing materials, from liability for any claims by me or any third party in connection with my participation.

PLEASE ONLY MARK WHAT YOU NEED TO BE ABLE TO HEAR AGAIN: I am a Cochlear Implant Recipient (if you are a Cochlear Implant recipient, please fill out the information in the section below)

Claiming an Advanced Bionics Harmony Sound Processor

PLEASE CHECK ONLY THE ITEMS THAT ARE BEING CLAIMED AS LOST OR BROKEN BELOW:

Side of processor being claimed: Left Right

Processor Serial #:

Sound processor color: Silver Metallic Dark Sienna Metallic Beige

Headpiece color (CI-5304): Silver Metallic Dark Sienna Metallic Beige

Coil Cable length: 4.25” 5.5" 9.5" 12"

Battery type: Powercel Plus (CI-5540) Powercel Slim (CI-5520)

Claiming an Advanced Bionics Auria Sound Processor

PLEASE CHECK ONLY THE ITEMS THAT ARE BEING CLAIMED AS LOST OR BROKEN BELOW:

Side of processor being claimed: Left Right

Processor Serial #:

Sound processor color: Silver Metallic Dark Sienna Metallic Beige

Headpiece color: Silver Metallic Dark Sienna Metallic Beige

Cable/coil length: 4.25" 5.5" 9" 12"

Battery type and color: (choose one) Powercel Plus (CI-5540) Powercel Slim (CI-5520) I have an Auria Powerpak

Claiming an Advanced Bionics Platinum Series Sound Processor

PLEASE CHECK ONLY THE ITEMS THAT ARE BEING CLAIMED AS LOST OR BROKEN BELOW:

Side of processor being claimed: Left Right

Processor Serial #:

Headpiece cable color: Beige Brown

Headpiece cable length: 18" 24" 32" 42" 48"

CLINIC/AUDIOLOGIST INFORMATION

Please explain why you are out of sound:

Please explain what assistance you have sought thus far. Do you have any insurance, or spoken to your clinic to see if you can get a loaner?

How long have you been out of sound?

Are there any additional comments or concerns?

I authorize CIAF to contact my Clinic/Audiologist I authorize my Audiologist to speak to CIAF

By submitting this form, I consent that all of the information submitted is to be true and accurate.

Application for Advanced Bionics

Associated fees for cochear implant assistance must be paid by applicant/patient to The Cochlear Implant Awareness Foundation after patient/applicants doctor approves equipment needs.