New Jersey Department of Health and Senior Services

Hearing Aid Assistance to the Aged and Disabled (HAAAD) Program

PO Box 715

Trenton, NJ 08625-0715

ELIGIBILITY APPLICATION

HEARING AID ASSISTANCE TO THE AGED AND DISABLED (HAAAD)

Address your reply to:

HAAAD Program

PO Box 715

Trenton, NJ 08625-0715

SECTION I: TO BE COMPLETED BY APPLICANT
Last Name
First Name
MI
Street Address
City
State
Zip Code
Applicant’s Social Security Number
Applicant’s Pharmaceutical Assistance to the Aged and Disabled (PAAD) Number
The following documentation must accompany this application:

1.	A receipt for the purchase of the hearing aid.

2.	A written statement from your physician attesting to the medical necessity for obtaining a hearing aid. You may obtain your physician's signature below or attach a copy of the prescription for the hearing aid.

APPLICANT'S CERTIFICATION AND WAIVER

I certify that the information above is true and accurate to the best of my knowledge. I understand that if it is determined that HAAAD benefits have been improperly issued to me, I will be required to repay such benefits. I understand that to verify my eligibility for HAAAD, it may be necessary to obtain certain information from the records of the Pharmaceutical Assistance to the Aged and Disabled (PAAD) Program, and I authorize the release of that information. I hereby assign to the State of New Jersey any right to hearing aid coverage to which I may be entitled under any other plan of assistance or insurance or from any other liable third party.
Signature of Applicant
Date
SECTION II: TO BE COMPLETED BY PHYSICIAN
I have examined this applicant and have determined the medical necessity for obtaining a hearing aid.
Name and Address of Physician (Print)
Signature of Physician
Date
J0000

WHAT IS HEARING AID ASSISTANCE TO THE AGED AND DISABLED?

This is a State of New Jersey program which provides a $100 reimbursement to eligible residents who purchase a hearing aid.

HOW DO I APPLY?

If you are currently enrolled in the Pharmaceutical Assistance to the Aged and Disabled Program (PAAD), you must complete a HAAAD application and submit the following documentation:

1.	A receipt for the purchase of your hearing aid.

2.	A written statement from your physician attesting to the medical necessity for obtaining a hearing aid.

If you are not currently enrolled in the PAAD program, you must complete a PAAD application as well. This is needed to verify your age or disability status, state residency, and annual income.

Applications may be obtained by calling the toll‑free number:

1-800-792-9745

HOW IS THE TERM "HEARING AID" DEFINED FOR THE PURPOSE OF THIS PROGRAM?

"Hearing aid" means a custom-fitted ear-level or body-worn electronic device to enhance communication for the hearing impaired.

HOW OFTEN MAY I RECEIVE THE HAAAD BENEFIT?

You may receive one $100 payment during a calendar year. If you purchase another hearing aid during a subsequent calendar year, you may reapply.

HOW SOON WILL I GET MY $100 PAYMENT AFTER I APPLY?

Once your application has been approved, you should receive your payment in approximately six to eight weeks.

WOULD I BE ELIGIBLE IF I HAVE OTHER HEARING AID COVERAGE?

If you are a Medicaid recipient or have other health insurance coverage or retirement benefits that provide full hearing aid coverage, you would not be eligible. If you have only limited or partial coverage, you would be eligible for a supplementary payment.

HOW DO I KNOW IF I AM ELIGIBLE?

You must be at least 65 years of age, or receiving Social Security Disability benefits.

You must be a New Jersey resident.

For 2012, you must have an annual gross income of less than $25,312 if you are single, or less than $31,035 if you are married.

IF YOU HAVE ANY QUESTIONS ABOUT HAAAD, WRITE TO:

HAAAD

PO Box 715

Trenton, NJ 08625‑0715

or telephone the toll free number:

1-800-792-9745

HA-1

NOV 11

HA-1, Eligibility Application, Hearing Aid Assistance to the Aged and Disabled (HAAAD)

ha-1, eligibility application, hearing aid, assistance, elderly, aged, disabled, senior, application, senior benefits, SBUM, HAAAD Program, HAAAD

EWhite

2002-09-09

NJDHSS