903-521817 12/19
Third Party Certification of
Eligibility for IP CapTel Service
Internal use:
Provider: TMO
B. CERTIFYING PROFESSIONAL
I certify under penalty of perjury the following: (i) the IP-CTS User is an individual with hearing loss that necessitates
use of captioned telephone service; (ii) I understand that the captioning on captioned telephone service is provided by
a live communications assistant and is funded through a federal program; (iii) I have not been offered or provided any
direct or indirect incentive (financial or otherwise) tied to this consumer’s decision to use the service and I have not
been referred to the applicant by a TRS provider or its affiliates; (iv) I do not have a business, family, or social
relationship with the TRS provider or its affiliates and (v) no joint marketing arrangement exists between myself/my
organization and the TRS provider or its affiliates, and I have not made, nor do I have the opportunity to make, a profit
on the sale of IP-CTS equipment to consumers.
(please
specify)
Name:
Address:
SUITE #:
Phone Number:
Email:
Title:
Business Name:
o Physician/PA/Nurse o Audiologist o Gov. Program or Veteran Service Officer o Hearing Health Professional
(please print)
Apt#:
ST:
Zip:
(please print)
A. CAPTEL USER INFORMATION
Name:
Address:
City:
Phone Number:
Email:
Preference
(if any): o 840i o 880i o 2400i
ST:
Zip:
City:
This form must be signed by an independent third-party professional who is qualified to evaluate
your hearing loss and certify that you require captioning support in order to use the telephone.
WHO CAN SIGN?
Your audiologist, physician/PA/Nurse, Veteran Service Officer, or other qualified hearing health
professional.
INSTRUCTIONS
Fill in section A with CapTel User’s information
Certifying Professional fills out section B
(including signature and date)
Submit Form – By Email: Register@CapTel.com By Fax: (608) 238-3008
By Mail: CapTel, Inc. 450 Science Drive Madison, Wisconsin 53711
Once the form is received, we’ll contact you to schedule a free installation or delivery
1
2
3
This certification applies to IP-CTS (Internet-based) CapTel models only. Not applicable for non-Internet phone models, i.e. CapTel 840.
Per FCC requirements: Before captions feature can be activated, IP-CTS users must register by providing their name, contact information, birth date, and last four digits of their social
security number. Per FCC regulations, all user information is kept confidential. FEDERAL LAW PROHIBITS ANYONE BUT REGISTERED USERS WITH HEARING LOSS FROM USING INTERNET
PROTOCOL (IP) CAPTIONED TELEPHONES WITH THE CAPTIONS TURNED ON. IP Captioned Telephone Service may use a live operator. The operator generates captions of what the other
party to the call says. These captions are then sent to your phone. There is a cost for each minute of captions generated, paid from a federally administered fund. No cost is passed on to the
CapTel user for using the service. CapTel captioning service is intended exclusively for individuals with hearing loss. CapTel® is a registered trademark of Ultratec, Inc. (v5.6 10-19)
Signature
Date
Per FCC requirements all user information is kept confidential. Privacy policy available online at www.CapTel.com/privacy or by phone: 1-877-464-9149.
Questions? Contact Registration help:
click to sign
signature
click to edit
![]()
