To find out if you qualify for a cochlear implant or if you are interested in starting the implant process here at Indiana University Medical Center, you must submit the following:
   a. Provide an unaided audiogram performed within the last year with speech discrimination scores for both ears.
   b. Provide your current contact and insurance information.
   c. Provide completed case history form(s).
       • Adults – Complete Adult History Form
       • Pediatrics – Complete both Pediatric History Form and School Report Form

You can submit this information by fax (317-274-4949) to Linette Staley or by email to lstaley@iupui.edu.

Note: If records are emailed, audiograms must be scanned and attached. Please allow 2-3 weeks for review.

Click the links below for the necessary forms... print, complete, then fax, or scan and email.

Adult History Form
Pediatric History Form
School Report Form

For Your Initial CI Evaluation . .  .

You must bring functioning hearing aids for both ears. Please bring any other medical documentation regarding your hearing loss.