Forms

Financial Assistance for Hearing Aids Application – English  

Financial Assistance for Cochlear Implants 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 – 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 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-Spanish

Para considerar renovar a su hijo para el programa de ayuda económica, debe completar este formulario en su
totalidad.

Cochlear Implant Patient Guide – English

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

Cochlear Implant Patient Guide – Spanish

Informacion de Padres y Pacientes

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 – Spanish

Formulario Para Nuevo Paciente

Provider List

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

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.