Captioncall form 2026

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The document is a Professional Certification Form used to certify that a patient has hearing loss and requires CaptionCall services for effective telephone communication. It includes sections for patient and healthcare provider information, certification statements by the healthcare professional, and instructions for submitting the form.

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Click ‘Get Form’ to open the CaptionCall form in the editor.
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 address.
In the Desired product(s) section, select the options that apply: Home phone or iPad app.
Next, complete the Healthcare Provider Information section. Provide your business/practice name, street address, city, state, ZIP code, phone number, and email address.
Check all applicable professions that may certify hearing loss from the provided list.
In the Certification section, ensure you read and understand each statement before signing. Fill in your professional's name, title, and date of certification.
Once completed, save your changes and submit the form via fax at 1-888-531-1906 or email it to certification@captioncall.com.

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