To Begin the CI Candidacy Process
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 firstname.lastname@example.org.
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.
For Your Initial CI Evaluation . . .
You must bring functioning hearing aids for both ears. Please bring any other medical documentation regarding your hearing loss.