The Illinois Telecommunications Access Corporation runs a free, state-required program that provides amplified phones, captioned phones, TTYs, hard-of-hearing cell phones and cell phone amplifiers. Page 2 of the new client application is signed by a doctor or other certifier confirming the applicant is deaf, hard of hearing, late-deafened, speech disabled or deaf-blind to the extent they cannot use a standard telephone.
The client completes page 1: contact details, last four digits of the Social Security number, disability and equipment. A doctor, nurse practitioner, physician assistant, audiologist, licensed hearing-aid dispenser, speech-language pathologist or DHS counselor for the deaf completes page 2: disability, Braille reading, permanence, equipment, license and signature.
Download the current version from the source each time; forms change without notice.
ITAC New Client Application
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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The form lists the applicant's doctor or nurse practitioner, an audiologist, a licensed hearing-aid dispenser, a DHS counselor for the deaf, or a speech-language pathologist; ITAC's website adds physician assistants. The certifier affirms the applicant is deaf, hard of hearing, speech disabled or deaf-blind to the extent they cannot use a standard telephone.
Yes. ITAC says applicants can complete the entire process at itac-apply.org, including getting the doctor's or professional's signature. The paper application can instead be printed, signed on page 2, and mailed with a copy of a recent phone bill and proof of residency.