Washington DSHS 14-264: Telecommunication Equipment

Washington's Office of the Deaf and Hard of Hearing runs the Telecommunication Equipment Distribution program, supplying amplified phones, TTYs, iPads or iPhones, electrolarynx devices and ring signalers to residents aged 4 and up who are deaf, hard of hearing, late-deafened, deaf-blind or speech disabled. Section 5 of this eight-page application is the professional's certification of the hearing loss or speech disability.

Who completes it

The applicant completes Sections 1 to 4: contact details, family size and income, disability, communication preferences, equipment choice and signature. A professional authorized to work in Washington signs Section 5, checking their profession and giving contact information and any license or certificate number.

Submitting and payment

How to submit it
Detach pages 6 to 8 and mail them to ODHH's TED Program or send them electronically to ODHH; incomplete applications may be returned.
Who pays
The form lists no fee for the professional; the applicant may owe a sliding-scale equipment cost based on family size and income, invoiced by ODHH, though many pay nothing and waivers are possible.

Good to know

  • WAC 388-818-010 authorizes certifiers including Department of Health licensed providers, audiologists, hearing aid fitters, deaf or deaf-blind specialists, nonprofit staff, state agency staff, VR counselors, occupational therapists and speech pathologists.
  • By signing, the professional attests they know the extent of the hearing loss or speech disability and believe the applicant can benefit from the equipment chosen in Section 3.
  • Applicants pick one telecommunication device and one signaler; delivery takes four to eight weeks, and some items are delivered and set up by a contracted trainer.
  • Reapplying is allowed after three years only if the current TED equipment no longer works or meets the applicant's needs.

Get the official form

Download the current version from the source each time; forms change without notice.

Application for Telecommunication Equipment

Fill it with Vero

If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

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Frequently asked questions

Who can sign Section 5 of DSHS 14-264?

A professional authorized to work in Washington, such as a doctor, audiologist, hearing aid fitter or dispenser, deaf or deaf-blind specialist, nonprofit representative, state agency employee, vocational rehabilitation counselor, occupational therapist or speech pathologist. Others write in their profession and include contact information so the program can verify it.

Does income affect eligibility for Washington's TED program?

No. Anyone who meets the residency, age and disability requirements can apply regardless of income. Income and family size only set the applicant's cost on a sliding scale. ODHH sends a letter showing whether the equipment is free or what is owed, and payment is due before equipment is issued.

Is DSHS 14-264 available in other languages?

The application is published in English only, but ODHH will provide it in large print, Braille and other languages on request. Informational brochures about the TED program are available in English, English large print and Spanish.