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Form 8853 online Elk Grove California: What You Should Know

If you do not complete these forms, your hearing test may not be valid. For Patient Forms, just click the form, and you will be directed to submit. • Hearing Tests and Prescriptions (Forms 12 and 19): This is used to be filled out when applying for your hearing test. You can get this form at any hearing-impaired or hearing testing facility; If you do not fill this out, you're hearing record may be invalid. • Waiver of the Hearing Test (Form 14D): This form is used for a hearing patient with a current hearing loss who is receiving disability benefits. If you do not fill this out, your Hearing Loss Exemption claim may not be valid. • Eligibility Certificates — Eligibility Certificate for Hearing Loss (Form 1130): This form is filled out when applying for hearing loss benefits. • Medicare Bill(s): This is for people who are eligible for Medicare benefits but cannot receive them because of hearing loss due to age or another reason. If you are being denied benefits and are an eligible Medicare patient, you must complete a  Form 1404. You can get Form 1130. If you don't fill this out, your hearing loss claim will be invalid. • Waiver of the Hearing Test (Form 14D), Archer Medical Savings Account: This form is used when a hearing disability patient has an Archer Medical Savings Account which the disability benefits are paid out of. • Medicare Bill(s), Archer Medical Savings Account: If a disability patient has a Medicare Bill that contains the amount to be paid from their Archer Medical Savings Account, this form is filled out. You don't have to fill this out. Elk Grove Hearing Health Center 1555 Elk Grove Avenue Elk Grove, CA 95620 Phone: Fax: Mailing Address: P.O. Box 54600 Elk Grove, CA 95620 If you receive this form, and you believe that it is valid for any reason, but you are an eligible applicant, please notify Elk Grove Hearing Health Centers ASAP. This is a critical document necessary for your eligibility, so make sure to fill it out promptly. Failure to complete this form may result in invalid and potentially invalidating your hearing test results.

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