&nbps;
 
  1. Step 1
  2. Step 2
  3. Step 3
  4. Complete

Please complete the form below to submit a Certification of Hearing Loss/Order on behalf of your veteran/client.

    Applicant/Veteran Information
    Third Party Professional Information
    Unspecified
    Physician
    Audiologist
    Hearing Related Professional
    Government/Veterans Program (ex. VSO)
    Order/Certification Information
    Unspecified
    The applicant has high-speed Internet and telephone service where the phone will be used.
    The applicant does NOT have high-speed Internet. Please contact the applicant about other options. (Charges may apply depending on solution.)
    Unspecified
    CapTel 840i
    CapTel 2400i w/ Touchscreen
    I certify that the applicant authorizes me to transmit this certification and the information contained herein to Hamilton CapTel.
    I certify, under penalty of perjury, that: 1) this applicant has hearing loss that necessitates the use of Captioned Telephone Service; and 2) I understand that the service is provided by a live communications assistant and is funded through a federal program; and 3) I have not been offered or provided any direct or indirect incentive (financial or otherwise) tied to this consumer’s decision to use the service and I have not been referred to the applicant by a TRS provider or its affiliates; and 4) I don’t have a business (other than providing this form), family or social relationship with the TRS provider or its affiliates; and 5) no joint marketing arrangement exists between myself/my organization and Hamilton CapTel, and I have not made, nor do I have the opportunity to make, a profit on the sale of IP CTS equipment to consumers.
    (Please sign below using your mouse.) Clear