TAP Hearing Loss Certification, F-22554 (09/2026)

Completion of the TAP Hearing Loss Certification form meets the requirements of Wisconsin Statute § 46.297 and Wisconsin Administrative Rule Chapter DHS 78.

Personally identifiable information (PII) on this form will be used to determine eligibility for assistance through the program and will be used only for this purpose.

This certification must be completed by a licensed physician, audiologist, or hearing instrument specialist. A printable fillable version of this form is also available at https://www.dhs.wisconsin.gov/library/collection/f-22554.

Contact the TAP Program Coordinator at DHSTAP@dhs.wisconsin.gov or 608-266-2536 if you have any questions about this form or the TAP program.

Section 1: TAP applicant information *This question is required.

First name *This question is required.

Last name *This question is required.

Street address (include unit number if any) *This question is required.

City *This question is required.

State *This question is required.

ZIP code *This question is required. This question requires a valid number format.

Phone number *This question is required.

Section 2: To be completed by a licensed physician, audiologist, or hearing instrument specialist.

For the purpose of this verification, this applicant has been tested and determined to be: *This question is required.

Profession (select one) *This question is required.

Please enter an 'other' value for this selection. * This question is required.

Signature of professional verifying information *This question is required.

Clear

Print Name

License number *This question is required.

Date examined *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

Date signed *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

Please provide your contact information in case we need to follow-up with you.

Phone number *This question is required.

Email address (if available) This question requires a valid email address.

* Hearing Instrument Specialists must include copies of exam results/reports, pursuant to Chapter HAS 4, and tests must have been performed within the last six months of the submitted TAP application. *This question is required.Must include exam copies from a pure tone audiometry, including air conduction testing and bone conduction testing and at least one of the following. Select all that apply.

Speech audiometry by live voice, or recorded voice, including speech reception threshold, speech discrimination testing, and most comfortable loudness measurements and loudness levels.
Appropriate masking when indicated.
Summary of findings or recommendations of audiograms and speech audiometry to determine proper selection and adaptation of hearing instruments.

Section 3: Upload exam results and reporting documentation here, if applicable. (Maximum files: 5, Maximum file size: 2 MB) *This question is required.(Upload-able file types: .png, .gif, .jpg, .jpeg, .doc, .xls, .docx, .xlsx, .pdf, .txt)

File: {{filename}} delete

Please use the submit button below to submit this information to the TAP Program Coordinator.

TAP Hearing Loss Certification, F-22554 (09/2026)

Telecommunication Assistance Program (TAP) Hearing Loss Certification