CCHAT – Information for Healthcare Professionals

When a child is diagnosed with hearing loss, her audiologist should contact CCHAT. We will facilitate shipment of a hearing aid directly to the practicing audiologist. CCHAT has partnered with Phonak and Oticon to provide patients with hearing aids.

New Applicants

If you have a patient who is interested in seeking financial assistance through CCHAT, submit a completed Provider Application (if a new provider) as well as a completed Hearing Aid Request form. You will need the following information:

1. The patient’s most current audiogram, taken within the last six months

2. Other tests that may be needed for diagnosis

3. Physician visit forms (if applicable)

4. Your Ohio license number

Additional Forms to be Submitted by the Practicing Audiologist

Once the hearing aid order has been placed, the CCHAT coordinator may contact the dispensing audiologist to complete additional forms needed for the CCHAT applicant.

After Form Submission

1. Please instruct your patient’s guardian to visit our website, (use the following shortcut: https://www.cincinnatichildrens.org/service/o/otolaryngology/cchat). The guardian will need to visit the Patient Education page to complete the application process. The hearing device will not be ordered until the guardian contacts the CCHAT coordinator.

2. After the guardian has contacted the CCHAT coordinator, the next steps for application process will be discussed and the hearing aid order will be placed.

3. The hearing device will be sent to the practice within 48 hours after the guardian has contacted the CCHAT coordinator.

4. The audiologist will be reimbursed at the time of hearing aid funding.

Forms to Download

The following forms can be downloaded in portable document format (.pdf). You must have Adobe Reader installed on your computer to read the files.

• Provider Application (PDF)
• Provider Application (Microsoft Word)
• Hearing Aid Request Form (PDF)
• Hearing Aid Request Form (Microsoft Word document)

Forms for Audiologists at Cincinnati Children’s to Download

• Cincinnati Children’s Provider Application (PDF)
• Cincinnati Children’s Provider Application (Microsoft Word document)
• Cincinnati Children’s Hearing Aid Request Form (PDF)
• Cincinnati Children's Hearing Aid Request Form (Microsoft Word document)