Professional Certification Form

Please complete and submit this digital certification form to certify that your patient has hearing loss and needs CaptionCall to communicate effectively on the phone. Thank you for referring CaptionCall!

By clicking Submit Form, you certify the following:

  • I certify, under penalty of perjury, that I am a hearing-care or healthcare professional and am qualified to diagnose hearing loss.

  • I certify that I have determined that the patient referenced has a hearing loss that makes it difficult to communicate effectively by telephone and requires the use of captioned telephone service to communicate by telephone in a manner that is functionally equivalent to a fully hearing person.

  • I certify that both I and the patient understand that the captioning service is provided by a live Captioning Agent and that this service is funded through a federal program for the hearing impaired.

  • I certify that I do not have any business, family or social relationship with any employee of Sorenson Communications or CaptionCall.

  • I certify that the patient has explicitly authorized me to request that CaptionCall contact him or her regarding CaptionCall captioning services using the contact information provided.
CC Logo with man against green wall

By clicking Submit Form, you certify the following:

I certify, under penalty of perjury, that I am a hearing-care or healthcare professional and am qualified to diagnose hearing loss.

I certify that I have determined that the patient referenced has a hearing loss that makes it difficult to communicate effectively by telephone and requires the use of captioned telephone service to communicate by telephone in a manner that is functionally equivalent to a fully hearing person.
I certify that both I and the patient understand that the captioning service is provided by a live Captioning Agent and that this service is funded through a federal program for the hearing impaired.
I certify that I do not have any business, family or social relationship with any employee of Sorenson Communications or CaptionCall.
I certify that the patient has explicitly authorized me to request that CaptionCall contact him or her regarding CaptionCall captioning services using the contact information provided.

CC Logo with man against green wall
FEDERAL LAW PROHIBITS ANYONE BUT REGISTERED USERS WITH HEARING LOSS FROM USING INTERNET PROTOCOL (IP) CAPTIONED TELEPHONES WITH THE CAPTIONS TURNED ON. IP captioned telephone service may use a live operator. The operator generates captions of what the other party to the call says. These captions are then sent to your phone. There is a cost for each minute of captions generated, paid from a federally administered fund. Professional certification of hearing loss and the need for captions to use the phone effectively are required to receive the CaptionCall service and phone at no cost. No costs are passed along to individuals who qualify for the service.