Hamilton CapTel Certificate of Hearing Loss/Order Form

Download the Certificate of Hearing Loss/Order Form

If you have a patient with hearing loss that would benefit from Hamilton® CapTel®, it’s never been easier to order a no-cost¹ Hamilton CapTel Phone. If you have any questions, please call 877-455-4227 or send e-mail to order@hamiltoncaptel.com.

Step #1

Download the Certificate of Hearing Loss/Order Form
Or provide your patient with a pre-printed form. If you’d like to order pre-printed forms, please call 877-455-4227.
Step #2

Complete the form in its entirety. This requires your patient’s information and signature, as well as the signature of a Physician, Audiologist or Hearing Related Professional verifying your patient has a qualified hearing loss.
Step #3

Submit the signed Certificate of Hearing Loss/Order Form as directed. Delivery typically takes 1-3 weeks.

Complete the Online Certificate of Hearing Loss/Order Form

For quicker processing, complete the form online!

Complete The Online Form

¹*Independent third-party professional certification required.

FEDERAL LAW PROHIBITS ANYONE BUT REGISTERED USERS WITH HEARING LOSS FROM USING INTERNET PROTOCOL (IP) CAPTIONED TELEPHONES WITH THE CAPTIONS TURNED ON. Automatic speech recognition software generates captions of what the other party to the call says, and, in certain circumstances, a live communications assistant may be included on the call to make needed corrections and/or add call details. The captions are then sent to the phone. There is a cost for each minute of captions generated, paid from a federally administered fund. To learn more, visit fcc.gov. Third-party charges may apply: the Hamilton CapTel phone requires high-speed internet access (Wi-Fi capable) and in some cases, may require telephone service. When using Hamilton CapTel on a smartphone or tablet and not on Wi-Fi, a data plan is required. Hamilton CapTel may be used to make 911 calls but may not function the same as traditional 911 services. For more information about the benefits and limitations of Hamilton CapTel and Emergency 911 calling, visit HamiltonCapTel.com/911. Courtesy of Cisco Systems, Inc. Unauthorized use not permitted. “Noah” is a registered trademark of HIMSA II K/S in the USA. Outside the USA, “Noah” is a trademark of HIMSA II K/S. Third-party trademarks mentioned are the property of their respective owners. CapTel is a registered trademark of Ultratec, Inc. Copyright ©2024 Hamilton Relay. Hamilton is a registered trademark of Nedelco, Inc. d/b/a/ Hamilton Telecommunications.
Third-party charges may apply: the Hamilton CapTel phone requires telephone service and high-speed Internet access. Wi-Fi capable.

Download the Certificate of Hearing Loss/Order Form

Step #1

Step #2

Step #3

Complete the Online Certificate of Hearing Loss/Order Form