Do I Qualify? Lighthouse Hearing Services Prequalification Questionnaire (Adult) Lighthouse Hearing Services Prequalification Questionnaire (Adult) 1. Have you lived in Georgia for a minimum of 12 consecutive months (leading up to today)? * Yes No 2. Do you have a valid Georgia driver’s license or Georgia Identification card? * Yes No 3. Are you 19 years of age or older? * Yes No 4. Does your insurance provide coverage for hearing aids? * Yes No Not applicable; I don’t have insurance 5 .Only answer if you responded “yes” to question 4: If your insurance provides coverage for hearing aids, are you partially or fully insured by a high deductible insurance plan (at least $1,350 for an individual or $2,700 for a family)? * Yes No Not applicable; I don’t have insurance 6. We serve adults with a household income up to 200% of the federal poverty guidelines. Is your household income at or below 200% of the federal poverty guidelines? * Yes No If you are human, leave this field blank. Submit
