Form Dhec 221 PDF Details

Navigating the pathway to becoming a licensed hearing aid specialist in South Carolina necessitates familiarity with the DHEC 221 form, a crucial document for professionals in this field. Drafted by the Bureau of Health Facilities Licensing, this form serves as the Application for License - Hearing Aid Specialist. It adheres strictly to stipulations outlined in §40-25-10 of the South Carolina Code of Laws, 1976, as amended, alongside Regulation 61-3, which mandates the annual filing of an application under oath for current and prospective licensees seeking eligibility to fit and sell hearing aids. The form's comprehensiveness is evident in its detailed request for personal and professional information, including reason for application, personal contact details, primary and any secondary business locations within South Carolina, educational background, and proof of equipment calibration. It further extends to verification of the applicant's statements through a sworn declaration, thereby underscoring the state's rigorous standards for licensure in this specialized domain. With licenses maintaining a validity of 12 months from the date of issue, this form lays the foundation for ensuring that only qualified individuals are authorized to provide hearing aid services, thereby safeguarding public health and ensuring the welfare of those requiring hearing assistance.

QuestionAnswer
Form NameForm Dhec 221
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesD 0221 sc dhec hearing aid license form

Form Preview Example

Application for License - Hearing Aid Specialist

Bureau of Health Facilities Licensing

(In accordance with §40-25-10, of the South Carolina Code of Laws, 1976, as amended, and Regulation 61-3, licensees and prospective licensees must file an application under oath in order to become eligible for licensure to fit and sell hearing aids, and annually thereafter. Licenses are effective for a 12-month period following the date of issue.)

l.Reason for application:

a.l Hearing Aid Specialist License

b.

Number: HAS-____________

2.Name: _____________________________________________________________________________________________

 

First

 

 

Middle Initial

Last

Prefix: Mr.

Mrs.

Ms.

Dr.

Other: _____ Generation Suffix __________ (i.e. Sr., Jr., III, etc)

3.Personal Contact Information:

a.E-mail Address: __________________________________________________________

b. Mobile Phone Number: ___________________

Home Phone Number: ___________________

c.Home Address: ___________________________________________________________________________________

Street (or PO Box)

City

State

Zip

d.Non-South Carolina Hearing Aid Business Address:

Business Name: ___________________________________________________________________________________

_________________________________________________________________________________________________

Street (or PO Box)

City

State

Zip

e.Mail Delivery by Department (check only one):

Home Address

Non-South Carolina Business Address

SC Primary Business Address

4.Primary Business Location (the South Carolina address which will be listed on your license):

a.Name of Business: _________________________________________________________________________________

b.Location Address: _________________________________________________________________________________

Street

City

State

Zip

c.Location Phone Number: _____________________________

d.Days and Hours of Operation: _______________________________________________________

e.Primary Business Mailing Address (if different from 4.b. above):

_______________________________________________________________________________________________

Street (or PO Box)CityStateZip

____________________________________________________________________________________________________________

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5.Secondary (satellite) Location(s): Please complete the following information for each additional South Carolina location at which you choose to be licensed, (if additional space is needed, attach a separate sheet of paper):

(Do not list the Primary Location from line 4 in this section)

Name of Business: ___________________________________________________________________________________

Street: _____________________________________ City: ____________________ State: ____ ZIP: _______________

Phone No: __________________________________ Days & Hrs of Operation: __________________________________

Name of Business: ___________________________________________________________________________________

Street: _____________________________________ City: ____________________ State: ____ ZIP: _______________

Phone No: __________________________________ Days & Hrs of Operation: __________________________________

Name of Business: ___________________________________________________________________________________

Street: _____________________________________ City: ____________________ State: ____ ZIP: _______________

Phone No: __________________________________ Days & Hrs of Operation: __________________________________

Name of Business: ___________________________________________________________________________________

Street: _____________________________________ City: ____________________ State: ____ ZIP: _______________

Phone No: __________________________________ Days & Hrs of Operation: __________________________________

Name of Business: ___________________________________________________________________________________

Street: _____________________________________ City: ____________________ State: ____ ZIP: _______________

Phone No: __________________________________ Days & Hrs of Operation: __________________________________

Name of Business: ___________________________________________________________________________________

Street: _____________________________________ City: ____________________ State: ____ ZIP: _______________

Phone No: __________________________________ Days & Hrs of Operation: __________________________________

Name of Business: ___________________________________________________________________________________

Street: _____________________________________ City: ____________________ State: ____ ZIP: _______________

Phone No: __________________________________ Days & Hrs of Operation: __________________________________

Name of Business: ___________________________________________________________________________________

Street: _____________________________________ City: ____________________ State: ____ ZIP: _______________

Phone No: __________________________________ Days & Hrs of Operation: __________________________________

____________________________________________________________________________________________________________

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6.Date of birth: _________________________ (Initial applicants only)

7.of conviction, type of offense and name and location of court. ___________________________________________________

____________________________________________________________________________________________________

8.Have you ever held a hearing aid specialist/dealer license, apprentice license or temporary permit in another state?

If yes, list the state(s) and expiration date(s): _______________________________________________

___________________________________________________________________________________________________

places.

9.List the name of the principal manufacturer for which you are a dealer: _________________________________________

Other manufacturers utilized: ___________________________________________________________________________

____________________________________________________________________________________________________

10.Enclose proof of attendance of continuing education. Only courses that have been approved in accordance with §40-25-50

(D) of the S.C. Code of Laws may be submitted. (This eight-hour requirement begins the second full licensing year.)

Name of Course

Dates Attended

No. Credit Hrs

11.Attach a copy of the actual documentation of current calibration (within the past 12 months) for each audiometer in use.

12.Enclose a $50 check or money order payable to DHEC for the license fee (see Regulation 61-3 for current fees).

13.

Verification:

State of: ______________________________ County of: _______________________________________

 

I,

 

 

do hereby swear or affirm, depose and say that I have read the foregoing application and

 

know the contents thereof, and that the statements made therein are true and correct to the best of my knowledge and belief.

 

_____________________________________

 

 

 

 

Signature

 

 

Subscribed and sworn to before me this _____day of _______________, _________

 

 

 

 

(Month)

(Year)

_________________________________________

Notary Public

My commission expires: ___________________ NOTARY SEAL

14.Please complete all applicable items (print legibly in ink or type) and mail to: SCDHEC, Health Facilities Licensing

Bureau, 2600 Bull Street, Columbia, SC 29201

____________________________________________________________________________________________________________

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Instructions for Completing DHEC Form 0221

Application for License as a Hearing Aid Specialist

Bureau of Health Facilities Licensing

PURPOSE: In accordance with §40-25-10, of the South Carolina Code of Laws, 1976, as amended, and Regulation 61-3, licensees and prospective licensees must file an application under oath in order to become eligible for licensure to fit and sell hearing aids, and annually thereafter. Licenses are effective for a 12-month period following the date of issue.

INSTRUCTIONS:

Line 1.a. If this is your first time applying for a license, check this block.

Line 1.b. If you are renewing your license, check this block and enter your license number.

Line 2. Enter the name of the individual applying for the license.

Line 3.a. Enter the e-mail address at which you want the Department to correspond.

Line 3.b. Enter your mobile and/or your home phone number at which you can best be reached by the Department.

Line 3.c. Enter your home address.

Line 3.d. If applicable, enter your non-South Carolina hearing aid business address.

Line 3.e. Check the appropriate block to where you want the Department to send mail related to your hearing aid license (check only one block).

Line 4.a. Enter the name of the primary business where you will be working (only South Carolina locations can be listed).

Line 4.b. Enter the location address of the business which must be the same as the address that will be listed on your license.

Line 4.c. Enter the area code and telephone number of the business.

Line 4.d. Enter the days and hours of operation of the business.

Line 4.e. Enter the primary business mailing address if it is different from the location address of the business.

Line 5. Enter each secondary satellite locations where you work other than the primary business location listed in Line 4 (only South Carolina locations can be listed).

Line 6. Enter the date of birth of the individual listed on Line 2, if applying for an initial license (must be twenty-one years of age or older to be licensed in the State of South Carolina.

Line 7 - 14. Self-explanatory. Complete as indicated. Attach additional sheet(s) if necessary.

OFFICE MECHANICS AND FILING: Kept in accordance with records retention schedule 16327 – retain at Agency for 4 years then to State Records Center for 6 years, and then destroy.

____________________________________________________________________________________________________________

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