Certificate of Hearing Loss Order Form

We’ve made it simple to complete a Certificate of Hearing Loss/Order Form. By completing the form online, your patient will receive a Hamilton CapTel Phone as quickly as possible.

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Other methods to complete the order form

FEDERAL LAW PROHIBITS ANYONE BUT REGISTERED USERS WITH HEARING LOSS FROM USING INTERNET PROTOCOL (IP) CAPTIONED TELEPHONES WITH THE CAPTIONS TURNED ON. Automatic speech recognition software generates captions of what the other party to the call says, and, in certain circumstances, a live communications assistant may be included on the call to make needed corrections and/or add call details. The captions are then sent to the phone. There is a cost for each minute of captions generated, paid from a federally administered fund. To learn more, visit fcc.gov. Third-party charges may apply: the Hamilton CapTel phone requires high-speed internet access (Wi-Fi capable) and in some cases, may require telephone service. When using Hamilton CapTel on a smartphone or tablet and not on Wi-Fi, a data plan is required. Hamilton CapTel may be used to make 911 calls but may not function the same as traditional 911 services. For more information about the benefits and limitations of Hamilton CapTel and Emergency 911 calling, visit HamiltonCapTel.com/911. Courtesy of Cisco Systems, Inc. Unauthorized use not permitted. “Noah” is a registered trademark of HIMSA II K/S in the USA. Outside the USA, “Noah” is a trademark of HIMSA II K/S. Third-party trademarks mentioned are the property of their respective owners. CapTel is a registered trademark of Ultratec, Inc. Copyright ©2025 Hamilton Relay. Hamilton is a registered trademark of Nedelco, Inc. d/b/a/ Hamilton Telecommunications.

Certificate of Hearing Loss Order Form

We’ve made it simple to complete a Certificate of Hearing Loss/Order Form. By completing the form online, your patient will receive a Hamilton CapTel Phone as quickly as possible.

Other methods to complete the order form

Download the Certificate of Hearing Loss/Order Form as a printable PDF

Install the HIMSA Noah® Module for your office patient management software