For providers adding an additional Audiologist or Dispenser to your practice, please fill out the following form:

Add a provider to your Practice


To download a copy of the Provider Application, Click Here

Provider Information - Section 1

Please fill in all of the fields. Do not close the window, otherwise your progress will be lost. This application will have THREE sections and an Agreement section. Each section must be submitted before continuing to the next. As soon as you submit one section you will not be able to go back. If you would like the printable application please click the above link.

Provider Details

Provider Name (Required)

Professional Title (required)
NPI Number (required)
Provider Phone (required)
Social Security Number (required)
Provider Email (required)
Date of Birth (required)

Professional Credentials

Professional Affiliations

Audiologist License #
Hearing Aid Dispensing #
Board CertificationYesNo
Board Expiration Date
ASHA Expiration Date
Medicaid # (if applicable)
Medicare # (if applicable)

Work History

(Please provide work history for the past 6 years, any gaps exceeding 6 months provide an explanation. If you require additional space, please fill in the first two and attach additional documentation below by clicking on the "UPLOAD" button.)

Place of Employment



Place of Employment



Please attach any additional work history (file-size limit is 2MB)

Have you ever been asked to resign or been terminated from any of the positions above?
Yes (if yes, please provide an explanation below)No

Termination Reason


Upload Supporting Documents

Please upload your supporting documents including:

  • license
  • insurance
  • diploma (if applicable)
  • W-9

    (file-size limit is 2MB)



    To be filled out if you omit a copy of your degree/diploma. If you have a copy of your diploma, please upload it at the end of this form (in the submission checklist section)

    Name of School

    Highest Level of Education
    High SchoolAssociatesBachelorsMastersDoctorate
    Graduation Date

    I, the undersigned, understand that by not providing a copy of my degree / diploma with the HCS provider application, I am verbally verifying my degree is valid and that Hearing Care Solutions, Inc. may use this information for any credentialing needs. I attest this information is true and accurate to the best of my knowledge.

    Print Full Name (Required)
    Please sign below (with your mouse)

    Check here if you accept these terms.