NCIP Cochlear Implant
Referral Form for Adults
(19 years and over):
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To ensure your referral is accepted and actioned immediately it is vital we receive the complete information requested in the form below.
If you are not an audiologist, fill in the form as best you can.
We can only process the referral once we have all the 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 *
Your name and title *
Your work address
Your work phone *
Your email 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
Is an interpreter needed?
If yes, what type?
Clients Email
Do they wear hearing aids?
If no please tell us why.
Make the model of hearing aids
Earmould type
Additional information. (E.g.Family situation, mental health issues, motivation).
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).
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Information Required
Copy of client’s New Zealand birth certificate, passport or New Zealand residency visa.
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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.
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Information Required
Please attach all the following audiological information:
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Current diagnostic audiogram (speech audiometry, immittance audiometry, and if available otoacoustic emissions)
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Previous audiograms & speech audiometry
Copies of any ENT reports (if available)
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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.
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Information Required
Please enclose:
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Print out of settings
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Real ear measures
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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
​
The Northern Cochlear Implant Trust holds contracts with the Ministry of Health and Ministry of Education for the Northern Cochlear Implant Programme. Patients eligible for a publicly funded cochlear implant receive services from the providers below:
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