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

Add a provider to your Practice

 

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

Professional Credentials


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.)

Drop a file here or click to upload Choose File
Maximum upload size: 10.49MB

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.)

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

Drop a file here or click to upload Choose File
Maximum upload size: 10.49MB
Drop a file here or click to upload Choose File
Maximum upload size: 10.49MB
Drop a file here or click to upload Choose File
Maximum upload size: 10.49MB
Drop a file here or click to upload Choose File
Maximum upload size: 10.49MB

Education


Provider Newsletter

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.