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Professional Certification Form

Please complete and submit this digital certification form to certify that your patient has hearing loss and needs CaptionCall to communicate effectively by phone. Thank you for referring CaptionCall!

By clicking Submit, you certify the following:
  • I certify, under penalty of perjury, that I am a hearing-care or healthcare professional and am qualified to diagnose hearing loss.
  • I certify that I have determined that the patient referenced has a hearing loss that makes it difficult to communicate effectively by telephone and requires the use of captioned telephone service to communicate by telephone in a manner that is functionally equivalent to a fully hearing person.
  • I certify that both I and the patient understand that the captioning service is provided by a live Captioning Agent and that this service is funded through a federal program for the hearing impaired.
  • I certify that I do not have any business, family or social relationship with any employee of Sorenson Communications or CaptionCall.
  • I certify that the patient has explicitly authorized me to request that CaptionCall contact him or her regarding CaptionCall captioning services using the contact information provided.

Patient Information

Practice Information

Professional's Information

Missing Required Information

Thank you!

Please take a moment to download the professional certification form.

Download Certification Form

A CaptionCall Representative will contact you to schedule a demonstration for you and your staff, answer questions, and provide you with brochures and a demo phone for your office if desired.

If you don’t hear from our team within the next 5 business days, please let us know at 1-877-557-2227.

We look forward to working with you and rolling out the red carpet for your clients/patients.

To learn more about CaptionCall, visit www.CaptionCall.com
or call 1-877-557-2227

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Information is submitted through a secure network
CaptionCall does not share or sell patient or professional information

What is CaptionCall?

CaptionCall is a revolutionary phone for anyone with hearing loss. It provides amplification and superb sound quality while displaying smooth-scrolling captions on a large, easy-to-read screen. It lets your patients use the phone again with confidence. They’ll love how easy it is to use—anyone who knows how to use a phone will understand how to use CaptionCall.