NCIP Cochlear Implant Referral Form for Adults (19 years and over):
To ensure your referral is accepted and actioned immediately, it is vital that we receive the complete information requested (referral document and check list). If you are not an audiologist fill in the form as best you can. The referral will not be processed until we have all essential information so getting the name of your client’s audiologist will make the process faster. If your client does not meet referral criteria we are happy to arrange a private assessment on receipt of this form.

Referrer Details:

Date of referral

Referrer’s Name & Title

Work address

Work phone

Work E-Mail address

If you are not an audiologist who can we contact to get audiology information?

Client Details:

Client name

Date of birth

Client’s Address

Clients NHI (if known)

Client’s Home Phone

Client’s Mobile Phone 

Interpreter needed? What type.

Clients Email

Do they wear hearing aids? If no please explain why.

Make the model of hearing aids

Earmould type

Additional information. (E.g.Family situation, mental health issues, motivation).

Please ensure you have completed everything on the following checklist:
Enclosed copies of
Upload Document
Max File Size 15MB

Public Referral Criteria

 

NZ Residency

Adults will not be able to access services in the publically funded programme if they do not hold NZ citizenship or residency. (Potential candidates must also live in New Zealand for at least 183 days per year).

Information Required

Copy of client’s New Zealand birth certificate, passport or New Zealand residency visa. 

Baseline Audiometric Criteria

Presence of a severe hearing handicap as evidenced by speech audiometry that is ≤ 60% in the better hearing ear. (Pimax on CVC or AB words). 

Clients must previously have had sufficient hearing to have developed some spoken language.  

Information Required

Please attach all the following audiological information: 

  • Current diagnostic audiogram (speech audiometry, immittance audiometry, and if available otoacoustic emissions)

  • Previous audiograms & speech audiometry

Copies of any ENT reports (if available)

Hearing Aids

Hearing aids and moulds need to be optimized for the loss. If prescriptive targets have not been met make note of why this has occurred. If there is no residual hearing ear moulds are required to assess lip reading benefit. 

Information Required

Please enclose:

  • Print out of settings

  • Real ear measures

  

Private Referral Criteria

 

Baseline Audiometric Criteria

Presence of a severe hearing handicap as evidenced by speech audiometry that is ≤ 60% in either ear. (Pimax on CVC or AB words). 

Clients must previously have had sufficient hearing to have developed some spoken language.  

Information Required

Please attach all the following audiological information: 

  • Current diagnostic audiogram (speech audiometry, immittance audiometry, and if available otoacoustic emissions)

  • Previous audiograms & speech audiometry

Copies of any ENT reports (if available)

Hearing Aids

Hearing aids and moulds need to be optimized for the loss. If prescriptive targets have not been met make note of why this has occurred. If there is no residual hearing ear moulds are required to assess lip reading benefit. 

Information Required

Please enclose:

  • Print out of settings

Real ear measures