Provider Application

For providers adding an additional Audiologist or Dispenser to your practice, please fill out the following form:

Please fill in all of the fields. Do not close the window, otherwise your progress will be lost. This application will have THREE sections and an Agreement section. Each section must be submitted before continuing to the next. As soon as you submit one section you will not be able to go back. If you would like the printable application please click here.

Provider Application

Provider First Name (Required) *

Provider Middle Name

Provider Last Name (Required) *

Date of Birth (Required) *

Gender (Required) *

Provider E-mail (required) *

Credentialing E-mail

Professional Title (required) * Professional Title (required)

NPI Number (required) *

Provider Phone (required) *

Social Security Number (required) *

Professional Credentials

Professional Affiliations

Audiologist License #

Hearing Aid Dispensing #

Primary state of practice

List 3 professional reference (Name, Phone Number, and Title)

National Board for Certification in Hearing Instrument Sciences Certification

Yes

National Board for Certification in Hearing Instrument Sciences Certification Expiration Date

American Speech-Language-Hearing Association CCC-A

Yes

American Speech-Language-Hearing Association Certification Number

American Speech-Language-Hearing Association Certification Expiration Date

Medicaid # (if applicable)

Medicare # (if applicable)

Work History

(Please provide work history for the past 6 years, any gaps exceeding 6 months provide an explanation. If you require additional space, please fill in the first two and attach additional documentation below by clicking on the "UPLOAD" button.)

Place of Employment (required) *

From (required) *

Do you currently work here? (required) *

Yes

Title (required) *

Responsibilities (required) *

Place of Employment

From

Do you currently work here?

Yes

Title

Responsibilities

Please attach any additional work history, HCS requires work history for the past 6 years (file-size limit is 2MB)

Maximum upload size: 10.49MB

Have you ever been asked to resign or been terminated from any of the positions above? (required) *

Yes (if yes, please provide an explanation below)

Termination Reason

Supporting Documents

Please upload your supporting documents including:
• license • insurance • diploma (if applicable) • W-9

File Upload

Maximum upload size: 10.49MB

File Upload

Maximum upload size: 10.49MB

File Upload

Maximum upload size: 10.49MB

File Upload

Maximum upload size: 10.49MB

Education

Educational institution (required) *

Graduation Date (required) *

Educational institution

Graduation Date

I, the undersigned, understand that by not providing a copy of my degree / diploma with the HCS provider application, I am verbally verifying my degree is valid and that Hearing Care Solutions, Inc. may use this information for any credentialing needs. I attest this information is true and accurate to the best of my knowledge.

Print Full Name (Required) *

Signature (required) *

Clear

Professional Credentials

Work History

Supporting Documents

Please upload your supporting documents including: • license • insurance • diploma (if applicable) • W-9

Education

Please upload your supporting documents including:
• license • insurance • diploma (if applicable) • W-9