I am a:

Each Hearing Aid Benefit Plan member, including immediate and extended family, must complete this registration process to activate their benefit and receive a membership identification number. Each member will have an individual identification number.

Enter First Name Enter Last Name

Date of Birth: Year-Month- Day

Street Address

City Zip

State California County

Phone Number Alternate/Cell Phone

Email Re-Enter Email

Company/Organization Name

Company Group Number (from front of card)

Relationship to Member

Struggling to understand speech is a challenging experience. This Hearing Aid Benefit plan offers your and your family high quality hearing care with substantial savings. There are no insurance premiums to pay – you simply sign up and start saving right away on hearing care, name brand hearing aids, and batteries.

Hearing Aid History

I wear a hearing aid Yes No 

I have worn a hearing aid in the past Yes No 

I think I have a hearing loss Yes No 

Very commonly, people find that they can hear, but have trouble understanding, and this difficulty only increases when those with this type of loss are put in noisy situations or social gatherings.

Do you have this problem? Yes No Not Sure 

It is recommended that everyone over the age of 18 receive a baseline hearing test to determine if there is a hearing loss that could benefit from the use of hearing aids. Once a baseline audiogram has been established, it is important to be re-tested every three to five years to track any changes in hearing and/or the ability to understand speech. If you need a baseline test or if you are due to have your hearing re-tested, and you are over the age of 18, this service, among many others are completely covered by your Hearing Aid Benefit Plan with no out of pocket cost to you, as long as your receive care and services from the contracted provider in your area.

I do not think I have hearing loss,
however I am interested in scheduling a baseline test Yes No 

I would like my local provider to contact me with more information Yes No 

If applicable, list specific questions or hearing concerns that you would like to discuss with your licensed Hearing Healthcare Provider

Once you submit this information, you will receive a confirmation e-mail from containing your member identification number and information about your local in-network provider. If you set an appointment, be sure to give the provider your member identification number over the phone, and present your benefit card when you arrive for your appointment.

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