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Name of Applicant ____________________________Phone_________________ Address___________________________________________________________ DOB:___________Physician’s Name ____________________________________ Where did you learn of the ReHAB Program?______________________________
___Medicare ___SSI Veterans Administration medical benefits Other Insurance 4. Are you currently employed?_____________________________________ PLEASE NOTE: If you qualify for the ReHAB program through the Warren Center you may be fitted with either a new or reconditioned hearing aid according to your hearing aid needs and our availability of funding and donated aids. Because we always have a waiting list of clients needing ReHAB program aids, it is our request that you and your family consider donating the aid back to the Center if and when you are no longer able to receive value from it. Click here for printable version of application
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175 Union Street - Bangor, Maine 04401 (207) 941-2850 Toll Free in Maine - 1-877-542-9000 |