Form HFS3701I Appendix E-3B "Binaural Hearing Aid Questionnaire" - Illinois

What Is Form HFS3701I Appendix E-3B?

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

Form Details:

  • Released on February 1, 2014;
  • The latest edition provided by the Illinois Department of Healthcare and Family 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 fillable version of Form HFS3701I Appendix E-3B by clicking the link below or browse more documents and templates provided by the Illinois Department of Healthcare and Family Services.

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Download Form HFS3701I Appendix E-3B "Binaural Hearing Aid Questionnaire" - Illinois

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State of Illinois
Department of Healthcare and Family Services
APPENDIX E-3b
BINAURAL HEARING AID QUESTIONNAIRE
Patient Name
RIN
Birth Date
In order to make an informed decision for coverage of a binaural hearing aid system, the following information is
required:
1. Was the participant's hearing tested in an acoustically treated sound suite?
Yes
No
If the response is no, where were the hearing tests performed?
2. What date were the hearing tests performed?
By whom (please provide practitioner's name and type)?
3. Document the hearing test results below: (provide decibels and frequencies for both ears)
Right Ear
Left Ear
Please attach a copy of the comprehensive hearing tests performed.
Are there results from previous hearing tests that the practitioner reviewed for comparisons?
Yes
No
If the response is yes, what is the date of the previous testing and the results?
Were the tests performed by the current practitioner?
4. Please describe what other types of hearing devices have been used in the past, and whether these devices
were effective?
5. Why is it necessary this participant have a binaural system?
6. Please describe any additional factors unique to this patient that should be considered during the prior approval
review:
Audiologist/Physician/Practitioner signature and degree
Date
HFS 3701I (R-2-14)
State of Illinois
Department of Healthcare and Family Services
APPENDIX E-3b
BINAURAL HEARING AID QUESTIONNAIRE
Patient Name
RIN
Birth Date
In order to make an informed decision for coverage of a binaural hearing aid system, the following information is
required:
1. Was the participant's hearing tested in an acoustically treated sound suite?
Yes
No
If the response is no, where were the hearing tests performed?
2. What date were the hearing tests performed?
By whom (please provide practitioner's name and type)?
3. Document the hearing test results below: (provide decibels and frequencies for both ears)
Right Ear
Left Ear
Please attach a copy of the comprehensive hearing tests performed.
Are there results from previous hearing tests that the practitioner reviewed for comparisons?
Yes
No
If the response is yes, what is the date of the previous testing and the results?
Were the tests performed by the current practitioner?
4. Please describe what other types of hearing devices have been used in the past, and whether these devices
were effective?
5. Why is it necessary this participant have a binaural system?
6. Please describe any additional factors unique to this patient that should be considered during the prior approval
review:
Audiologist/Physician/Practitioner signature and degree
Date
HFS 3701I (R-2-14)