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Get Indiana Diagnostic Audiology Evaluation Form
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How to fill out the Indiana Diagnostic Audiology Evaluation Form online
This guide provides comprehensive instructions for users looking to complete the Indiana Diagnostic Audiology Evaluation Form online. Aimed at a wide audience, this step-by-step approach ensures clarity and accessibility for everyone involved in the evaluation process.
Follow the steps to effectively complete the form online.
- Press the ‘Get Form’ button to access the evaluation form, opening it in your preferred online editor.
- Begin by entering the referral date in the 'Referral Received' section along with the name of the person or organization making the referral.
- Complete the child’s last name, first name, and date of birth in the designated fields. Ensure that all required items, marked with an asterisk (*), are filled out.
- Provide the healthcare provider’s name or clinic, address, and phone number. Indicate whether it is a home or work number by checking the appropriate box.
- Specify the child's unique ID, primary language, and other personal details requested in the form, including the child’s birth hospital and whether they were screened at birth.
- In the evaluation section, fill in the audiologist’s name and clinic name, along with the date of evaluation and clinic phone number.
- Mark the evaluation status as completed or not completed, and provide the appropriate disposition, detailing any further evaluations or interventions needed.
- List any known risk factors as per the codes provided, and note whether you discussed early intervention with the family.
- Fill in the tympanometry results, auditory responses, and hearing thresholds as outlined, ensuring to check if the hearing is normal or indicating any loss.
- Review all information entered for accuracy, then save changes to your document. You can download, print, or share the completed form as required.
Complete this essential document online to facilitate better audiological support.
Failing a hearing test typically means that the individual does not respond to sounds within the expected range of hearing. This outcome necessitates further evaluation to determine the extent of hearing loss. Proper documentation via the Indiana Diagnostic Audiology Evaluation Form can play a crucial role in tracking results and guiding your next steps.
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