To Be
Completed By The Certifying Authority
304-558-1675
voice/tty - Toll Free 866-461-3578 voice/tty
I certify that the applicant named is unable to communicate
effectively on the telephone without the use of a TTY/TDD. Use of the device would benefit
the independent living skills of the named individual. Persons qualified to certify
applicant:
Ontologists (Ear, Nose & Throat Specialist); Audiologist (send copy of
audiogram); Doctor of Medicine; Registered Nurse; Professional staff of a Title and
occupation hospital, institution, public or welfare agencies (social
workers, Address case workers, counselors, teachers, principals and superintendents); or a
Pastor or Minister
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Name (type or print) |
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(Signature) |
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Title and Occupation |
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Address |
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City
State
Zip |
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Telephone |
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Date
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Patient/Client Name |
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