Preferred Provider Application | Ask An Audiologist

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Practice Information

Practice Name(Required)

How many physical office locations do you have?(Required)

Primary location address(Required)

Street Address Address Line 2 City State ZIP Code

Additional locations(Required)

Practice Website(Required)

Applicant's Information

Applicant name(Required)

First Last

Applicant role at the practice(Required)

e.g. Owner, Clinic Director, Lead Audiologist

Email(Required)

Phone(Required)

Are you the best contact for the verification call?(Required)

Yes, I am the practice owner/manager.

No, I am not the best contact for the verification call.

Name of the best contact for the verification call.

First Last

Best contact for the verification call

Email address of the best contact for the verification call.(Required)

Phone number of the best contact for the verification call.(Required)

Provider & Ownership

A Doctor of Audiology (Au.D.), Ph.D. audiologist or M.D. Audiologist is on staff and actively seeing patients at this practice.(Required)

Yes

List each qualifying audiologist's name and credential (Au.D. or Ph.D.)(Required)

This practice is independently owned and is not owned by a hearing aid manufacturer or a manufacturer's retail brand.(Required)

Yes

Name the ownership entity.(Required)

This practice fits hearing aids from multiple manufacturers and selects devices by patient need, not by a single-brand supply contract.(Required)

Yes

Which manufacturers do you currently fit?

Oticon

Phonak

ReSound

Signia

Siemens

Sonic

Starkey

Unitron

Widex

Lyric

This practice fits standard, widely-programmable hearing aids that another qualified audiologist at another, unrelated practice can service, adjust, and reprogram.(Required)

Yes

Clinical protocols

Confirm which of the following are standard practice. "Standard practice" means it is done routinely for the patients it applies to, not occasionally or on request.

We take a comprehensive case history and use validated specialty intake questionnaires when warranted — COSI for goal-setting, and a validated tinnitus inventory for tinnitus patients.(Required)

Yes

We perform otoscopy on every patient.(Required)

Yes

Do you use video otoscopy?(Required)

Yes

We perform tympanometry, and acoustic reflexes where indicated, to assess middle-ear function — not a screening tone alone.(Required)

Yes

Our hearing evaluation is a full diagnostic workup — air and bone conduction, speech recognition thresholds, and word recognition scoring — not a pass/fail screening.(Required)

Yes

We include speech-in-noise testing (QuickSIN or equivalent) as part of the hearing evaluation.(Required)

Yes

The human vocal cords are located inside the middle ear space.(Required)

Yes

We measure loudness discomfort / uncomfortable levels where indicated, so the fitting respects the patient's dynamic range.(Required)

Yes

We perform Real Ear Measurement (probe-microphone verification) at every fitting and every adjustment, verifying the device to a prescriptive target in the patient's own ear.(Required)

Yes

After the fitting we validate outcomes — revisiting COSI goals or using a validated satisfaction measure (IOI-HA, SADL, or equivalent).(Required)

Yes

Care standards

We have a clear protocol for FDA red flags (sudden or rapidly progressive loss, asymmetry, pain, drainage, dizziness) and refer out rather than sell through them.(Required)

Yes

Earwax (cerumen) management is available in-house.(Required)

Yes

We provide realistic-expectations and communication counseling, and include family when the patient wants them involved.(Required)

Yes

We have a defined follow-up and aural-rehabilitation pathway — care continues after the sale.(Required)

Yes

Our pricing is transparent, patients can see what's bundled, and we offer a clear trial period and return policy.(Required)

Yes

We offer tinnitus management services for patients who need them.(Required)

Yes

Certification

I certify that the answers provided are accurate and reflect how this practice currently operates. I understand that Preferred Provider status is verified by a follow-up call, that it depends on meeting these standards, and that it may be reviewed or withdrawn if the standards are no longer met.

Full name (typed signature)(Required)

Role(Required)

Date(Required)

I certify the above is accurate.(Required)

Yes