Forms

If you are in our coverage area you may apply for assistance, print the application and instruction letter.The Audiologist and the Medical Doctor will require your insurance card and ID. You are responsible for any deductible or co-pay your insurance requires.  You should discuss this with the Audiologist prior to your visit. Make certain that the testing audiologist will use an instrument supplied by the Lions Foundation if you are approved.

It may take up to 4 weeks to get approval. and several weeks after that before the instrument is ready to go to the Audiologist for your fitting. The application fee and increase in patient registration fee are effective January 1, 2018.

Please note: 

New Phone number -804-248-9938

If you are not in our coverage area do not use this form.

 

  Application Form and Instructions Version1117