GOS Eligibility Screening

Gift of Sound Application

Eligibility Screening
Thank you for your interest in the Miracle-Ear Foundation Gift of Sound program and congratulations on taking a step to address your hearing health! The following pre-screening questions will help you determine if you may be an eligible candidate to receive hearing aids through the Miracle-Ear Foundation. If this pre-screening identifies you as a potential candidate, you will be directed to fill out a formal application. For adult applicants, 19 and older, a $200 application fee is required before your application will be reviewed by the Miracle-Ear Foundation.

If you have not visited your local Miracle-Ear store, please use the Miracle-Ear Store Finder to identify the nearest location and contact them before starting the application process.

Gift Of Sound Application

Eligibility Questions
Applicant Type*
Applicant's First and Last Name*
First and Last Name
DOB*

MonthDayYear
Parent's Name*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Enter the Miracle-Ear Store's City and State below then select the correct store.

You must visit a Miracle-Ear store before you can apply. If you do not know your store's address or haven't contacted a store yet, please visit the Miracle-Ear Store Locator to verify.
Store City*
Store State*
Standard 2 Letter Abbreviation
Hidden Address Field
Store Address
Account Number
Account Name
Site Email
Additional Email
How did you hear about the Miracle-Ear Foundation?
Do you have a hearing loss that requires amplification?*
Have you previously received hearing aids from the Miracle-Ear Foundation?*
When did you receive your Miracle-Ear Foundation hearing aids? *
Can you provide documentation showing your income is at or below the following levels?*
Are you eligible to receive hearing aids through any other program or resource, including, but not limited to insurance, state Medicaid program, VA or vocational rehab, state or locally funded programs, other charity sources, or financing (determined by local Miracle-Ear store)?*
Child applicants (18 & younger) must submit a current audiogram completed in the last six months and receive medical clearance from a medical doctor or nurse practitioner. Are you able to complete both requirements?*
Should be Empty:

Gift of Sound Application