Professional certification form 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the 'Patient Information' section. Enter the patient's name, street address, city, state, ZIP code, phone number, preferred caption language, and email.
3. Next, complete the 'Healthcare Provider Information' section. Provide your business or practice name, promo code (if applicable), street address, city, state, ZIP code, phone number, and email.
4. In the certification section, check the applicable profession that certifies hearing loss. Ensure you provide your name and signature as a qualified healthcare professional.
5. Finally, review all entered information for accuracy before submitting. You can fax it to 1-888-531-1906 or email it to certification@captioncall.com.

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