Name of Applicant ________________________________________Phone_________________

Address___________________________________City____________________State_______Zipcode_________

DOB:___________Physician’s Name _______________________________________________

Where did you learn of the ReHAB Program?______________________________

1. How many persons are there in your family?___________
2. What is your total household monthly income?__________
3. Are you currently eligible for or covered by
___MaineCare (formerly called Medicaid)
if yes, number _____________________

___Medicare
if yes, number _____________________

___SSI
if yes, number _____________________

Veterans Administration medical benefits
if yes, last four digits of SS#___________

Other Insurance
if so, what ?________________________ ID#_____________________

4. Are you currently employed?_____________________________________
5. If not, could you be employed if you had a hearing aid?_________________
6. ReHAB clients are requested to make a small payment of from $2 to $25 to assist us in making aids available to others as well. What amount do you feel you could afford within that range?

PLEASE NOTE: If you qualify for the ReHAB program through the Warren Center you will be fitted with one hearing aid which will be either new or reconditioned according to your hearing aid needs and our availability of funding and donated aids.