Medical Forms Numeric Listing - Illinois 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient's name, RIN, and birth date at the top of the form. Ensure accuracy as this information is crucial for identification.
3. For question one, indicate whether the participant's hearing was tested in an acoustically treated sound suite by selecting 'Yes' or 'No'. If 'No', specify where the tests were conducted.
4. In question two, provide the date of the hearing tests and include the practitioner's name along with their type (e.g., audiologist).
5. Document the hearing test results in decibels and frequencies for both ears under question three. Attach a copy of comprehensive hearing tests if available.
6. Answer whether previous hearing test results were reviewed for comparisons. If yes, provide the date and results of those tests.
7. Describe any past hearing devices used and their effectiveness in question four.
8. Explain why a binaural system is necessary for this participant in question five.
9. Finally, detail any unique factors about the patient that should be considered during approval review in question six. Don’t forget to have the audiologist or physician sign and date at the bottom.

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