Form HA-1 "Eligibility Application, Hearing Aid Assistance to the Aged and Disabled (Haaad)" - New Jersey

What Is Form HA-1?

This is a legal form that was released by the New Jersey Department of Human Services - a government authority operating within New Jersey. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2021;
  • The latest edition provided by the New Jersey Department of Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form HA-1 by clicking the link below or browse more documents and templates provided by the New Jersey Department of Human Services.

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Download Form HA-1 "Eligibility Application, Hearing Aid Assistance to the Aged and Disabled (Haaad)" - New Jersey

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New Jersey Department of Human Services
Hearing Aid Assistance to the Aged and Disabled (HAAAD) Program
PO Box 715
Trenton, NJ 08625-0715
ELIGIBILITY APPLICATION
HEARING AID ASSISTANCE TO THE AGED AND DISABLED (HAAAD)
Address your reply to:
HAAAD Program
PO Box 715
Trenton, NJ 08625-0715
SECTION I: TO BE COMPLETED BY APPLICANT
Last Name
First Name
MI
Street Address
City
State
Zip Code
Applicant’s Social Security Number
Applicant’s Pharmaceutical Assistance to the Aged and
Disabled (PAAD) Number
The following documentation must accompany this application:
1.
A receipt for the purchase of the hearing aid.
2.
A written statement from your physician attesting to the medical necessity for obtaining a hearing aid. You may
obtain your physician's signature below or attach a copy of the prescription for the hearing aid.
APPLICANT'S CERTIFICATION AND WAIVER
I certify that the information above is true and accurate to the best of my knowledge. I understand that if it is determined that
HAAAD benefits have been improperly issued to me, I will be required to repay such benefits. I understand that to verify my
eligibility for HAAAD, it may be necessary to obtain certain information from the records of the Pharmaceutical Assistance to
the Aged and Disabled (PAAD) Program, and I authorize the release of that information. I hereby assign to the State of New
Jersey any right to hearing aid coverage to which I may be entitled under any other plan of assistance or insurance or from
any other liable third party.
Signature of Applicant
Date
SECTION II: TO BE COMPLETED BY PHYSICIAN
I have examined this applicant and have determined the medical necessity for obtaining a hearing aid.
Name and Address of Physician (Print)
Signature of Physician
Date
HA-1
JAN 21
New Jersey Department of Human Services
Hearing Aid Assistance to the Aged and Disabled (HAAAD) Program
PO Box 715
Trenton, NJ 08625-0715
ELIGIBILITY APPLICATION
HEARING AID ASSISTANCE TO THE AGED AND DISABLED (HAAAD)
Address your reply to:
HAAAD Program
PO Box 715
Trenton, NJ 08625-0715
SECTION I: TO BE COMPLETED BY APPLICANT
Last Name
First Name
MI
Street Address
City
State
Zip Code
Applicant’s Social Security Number
Applicant’s Pharmaceutical Assistance to the Aged and
Disabled (PAAD) Number
The following documentation must accompany this application:
1.
A receipt for the purchase of the hearing aid.
2.
A written statement from your physician attesting to the medical necessity for obtaining a hearing aid. You may
obtain your physician's signature below or attach a copy of the prescription for the hearing aid.
APPLICANT'S CERTIFICATION AND WAIVER
I certify that the information above is true and accurate to the best of my knowledge. I understand that if it is determined that
HAAAD benefits have been improperly issued to me, I will be required to repay such benefits. I understand that to verify my
eligibility for HAAAD, it may be necessary to obtain certain information from the records of the Pharmaceutical Assistance to
the Aged and Disabled (PAAD) Program, and I authorize the release of that information. I hereby assign to the State of New
Jersey any right to hearing aid coverage to which I may be entitled under any other plan of assistance or insurance or from
any other liable third party.
Signature of Applicant
Date
SECTION II: TO BE COMPLETED BY PHYSICIAN
I have examined this applicant and have determined the medical necessity for obtaining a hearing aid.
Name and Address of Physician (Print)
Signature of Physician
Date
HA-1
JAN 21
WHAT IS HEARING AID ASSISTANCE TO THE
HOW SOON WILL I GET MY $100 PAYMENT
AGED AND DISABLED?
AFTER I APPLY?
This is a State of New Jersey program which
Once your application has been approved, you
provides a $100 reimbursement to eligible
should receive your payment in approximately
residents who purchase a hearing aid.
six to eight weeks.
HOW DO I APPLY?
WOULD I BE ELIGIBLE IF I HAVE OTHER
HEARING AID COVERAGE?
If
you
are
currently
enrolled
in
the
Pharmaceutical Assistance to the Aged and
If you are a Medicaid recipient or have other
Disabled Program (PAAD), you must complete a
health insurance coverage or retirement benefits
HAAAD application and submit the following
that provide full hearing aid coverage, you would
documentation:
not be eligible. If you have only limited or partial
coverage,
you
would
be
eligible
for
a
1. A receipt for the purchase of your hearing
supplementary payment.
aid.
2. A written statement from your physician
HOW DO I KNOW IF I AM ELIGIBLE?
attesting
to
the
medical
necessity
for
obtaining a hearing aid.
You must be at least 65 years of age, or
receiving Social Security Disability benefits.
If you are not currently enrolled in the PAAD
You must be a New Jersey resident.
program, you must complete a PAAD application
as well. This is needed to verify your age or
For 2021, you must have an annual gross
disability status, state residency, and annual
income of less than $28,769 if you are single, or
income.
less than $35,270 if you are married.
Applications may be obtained by calling the
toll-free number:
1-800-792-9745
HOW IS THE TERM "HEARING AID" DEFINED
FOR THE PURPOSE OF THIS PROGRAM?
IF YOU HAVE ANY QUESTIONS ABOUT
"Hearing aid" means a custom-fitted ear-level or
HAAAD, WRITE TO:
body-worn
electronic
device
to
enhance
communication for the hearing impaired.
HAAAD
PO Box 715
Trenton, NJ 08625-0715
HOW OFTEN MAY I RECEIVE THE HAAAD
BENEFIT?
or telephone the toll free number:
You may receive one $100 payment during a
1-800-792-9745
calendar year. If you purchase another hearing
aid during a subsequent calendar year, you may
reapply.
HA-1
JAN 21
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