Gift of Sound™ Eligibility Screening

Thank you for your interest in the Miracle-Ear Foundation© Gift of Sound program and congratulations on taking a step to address your hearing health! The following pre-screening questions will help you determine if you may be an eligible candidate to receive hearing aids through the Miracle-Ear Foundation. If this pre-screening identifies you as a potential candidate, you will be directed to fill out a formal application.

If you have not visited your local Miracle-Ear store, please use the Miracle-Ear Store Finder to identify the nearest location.

General Information

Type of applicant

Please select... Adult (19 years & older) Child (18 years & under)

Applicant's Name (First Last)

Parent/Legal Guardian Name

Date of Birth

Phone Number

Email

Have you visited your local Miracle-Ear Store?

Please select... Yes No

Do you have a hearing loss that requires amplification

Please select... Yes No Unsure

Have you previously received hearing aids from the Miracle-Ear Foundation? 

Please select... Yes No

When did you receive your Miracle-Ear Foundation hearing aids?

Please select... Less than 3 years ago Between 3 and 4 years ago More than 5 years ago

How did you hear about the Miracle-Ear Foundation

Can you provide documentation showing your income is at or below the following levels?

Please select... Yes No

Are you eligible to receive hearing aids through any other program or resource, including, but not limited to insurance, state Medicaid program, VA or vocational rehab, state or locally provided/funded programs, other charity sources, or financing (determined by local Miracle-Ear store)? 

Please select... Yes No

Child applicants (18 & younger) must submit a  current audiogram completed in the last six months and receive medical clearance from a medical doctor or nurse practitioner. Are you able to complete both of these requirements?

Please select... Yes No