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TAP HAA Application, F-02743 (01/2021)

Telecommunication Assistance Program Hearing Aid Assistance (TAP HAA) Application

Notice: To apply, complete the TAP HAA application form. Applications will be processed in the order received and approved if it meets the program's income eligibility guidelines.

Applicants must provide hearing loss documentation (that is current within the past six months) and a hearing aid or cochlear implant external processor price quote from a vendor. TAP HAA program requires a Telecoil (T-coil) or Bluetooth program to be included and activated within the hearing aid or external processor to provide effective assistance to use telecommunication devices for distance communications. The
T-coil or Bluetooth programs must be documented on the quote.

If assistance is required to complete the application or there are any questions about the program, please call the TAP office at 608-267-7195 or contact us by email at DHSTAP@dhs.wisconsin.gov or visit our website at DHS TAP.

Please note: TAP HAA applicants can only apply once every three years.
1. Applicant information
This question requires a valid number format.
Phone Type:
This question requires a valid email address.
Enter your most recent annual adjusted gross income for your household, as reported on your Wisconsin Income Tax Return, OR total of all household income, including spouse if applicable, Social Security, wages, SSI, and other benefits. Proof of income may be requested.
This question requires a valid currency format.
This question requires a valid number format.
4. Applying for assistance with: (check only one) *This question is required.
5. I understand that I will need to include a quote for the total purchase of the hearing aid(s) and ONE of the following documents from the provider to complete my TAP HAA application. Documentation must be current within the past six months.

Select applicable documentation:
6. Upload your hearing loss certification documentation here, if available. Upload accepts up to 5 files with a max file size of 1 MB each.
Allowed types: png, gif, jpg, jpeg, doc, xls, docx, xlsx, pdf, and txt
7. Upload your hearing aid purchase quote documentation here, if available. Upload accepts up to 5 files with a max file size of 1 MB each.
Allowed types: png, gif, jpg, jpeg, doc, xls, docx, xlsx, pdf, and txt
Applicant Information:
  • Must include a quote from provider for hearing aid or cochlear implant external processor purchase with a telecoil or Bluetooth program included.
  • Financial assistance vouchers will be mailed to applicant or applicant's legal representative to be redeemed with the vendor (certified audiologist or licensed hearing aid provider) as a credit towards the total purchase price.
Provider Information:
  • Providers need to be approved as valid DHS vendors within the Wisconsin STAR accounts payable system.
  • Approved vendors will submit invoices to the TAP program following DHS payment guidelines located on the DHS TAP HAA Vendors webpage.
I certify that all information provided on this application, including information about applicant's income and hearing loss documentation, are true, complete, and accurate to the best of my knowledge. I authorize TAP program representatives to verify the information provided. I permit applicant's information to be exchanged as needed with internal and external agencies, organizations, or individuals as TAP program policies dictate for the administration of the program benefits and for the delivery of equipment and services to the applicant.
9. I agree and give consent. *This question is required.
Please note: this application will not be processed without consent.
12. Relationship, if not applicant.
If you are completing this application on behalf of the applicant, please include your contact information in case we have any questions about the information provided.
This question requires a valid email address.