Patient Forms

Financial Assistance Application - English

Application for the Carolina Children's Communicative Disorders Program (CCCDP). This financial assistance program helps pay for hearing aids, cochlear implant equipment, and other hearing care for children in North Carolina.

Financial Assistance Application - English - Read More…

Financial Assistance Application - Spanish

El programa de ayuda financiera del CCCDP proporciona fondos para audífonos para niños con pérdida auditiva cuyas familias no califican para ningún otro programa público y que no cuentan con los ingresos para obtener los audífonos.

Financial Assistance Application - Spanish - Read More…

Financial Assistance Renewal Form

Renewal application for the Carolina Children's Communicative Disorders Program (CCCDP). Please fill out this form if you are currently enrolled or have been enrolled in the program at any point in the past and wish to renew your child's status in the program.

Financial Assistance Renewal Form - Read More…

Cochlear Implant Patient Guide - English

Patient guide for families who are new the Children's Cochlear Implant Center at UNC.

Cochlear Implant Patient Guide - English - Read More…

New Patient Form

This form is for any patient who is new to our clinic. Please fill this out before your first visit with us. If you get stuck, we can help you fill it out during your visit.

New Patient Form - Read More…

Provider List

Please fill this form out whenever there is a change in your child's hearing care team.

Provider List - Read More…

Medical Records

We are not able to send audiograms or reports directly from our clinic. The parents must request these records directly from medical records. Forms for requesting medical records can be found on the Medical Center website via this link.

Medical Records - Read More…