Skip To Content

Complete the Online Certificate of Hearing Loss/Order Form

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

Step
  1. 1
  2. 2
  3. 3
Applicant Information
Name*
Address*
 

* Please provide at least one phone number to continue.

 

* Required information

Step
  1. 1
  2. 2
  3. 3
Healthcare Professional Information
Name*
Occupation*
Address*

* Required information

Step
  1. 1
  2. 2
  3. 3
Order/Certification Information
High-speed Internet and telephone service is required for use of the Hamilton CapTel phone. Please select one of the following.*
Please select the applicant’s requested Hamilton CapTel phone.*
Applicant Authorization*
Healthcare Professional Certification*
Signature*

(Please sign below using your mouse.)

* Required information

Live Assistance is available during the following hours:

Monday – Friday:
8:30 AM to 12:30 AM Eastern

Saturday, Sunday:
11:00 AM to 6:30 PM Eastern