Full Name *

Email *

Date Of Birth (Of Cochlear Implant Recipient) Click on year and month to change *

Mailing Address *

City *

State *

Country *

Postal code *

Name of cochlear implant recipient *

Name of cochlear implant Audiologist *

Cochlear implant clinic--include city and state *

What year was the recipient implanted? *

Phone *

If bilateral, please list sound processors on left and right ear.

Left Ear *

Right Ear *

Which product is being requested? PLEASE ONLY MARK WHAT IS NEEDED TO KEEP UNIT FUNCTIONING * *

Is the recipient currently without sound? *

Yes

Have you pursued your insurance, Medicare or Medicaid for this product? *

Yes

If yes, please explain why that option was not successful. *

If no, please explain why you haven't pursued that option. *

Please write a brief, personal explanation as to how receiving this product will impact the life of the recipient. The more information we receive, the quicker we will be able to respond. *

Please Check Below *

By checking this box, I confirm all of the information provided is true. I have read and agree to the terms and conditions set forth by JLCIF.

Requests for product support often exceed JLCIF's funds. By checking this box, I acknowledge that my application may not be approved for funding.

I understand and agree, that if my product request is approved, I am responsible for paying 20% of the total cost. *

Yes

How did you hear about us? *

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