Healthcare Audiology Services Form

Healthcare Audiology Services Form

Patient Information

Patient Name:

Male    Female    Other    Prefer not to say

Emergency Contact

Insurance Information

Medical & Hearing History

Do you use hearing aids?    Yes    No

History of noise exposure (work, recreation):

Tinnitus (ringing) present: Yes    No

Current Hearing Needs & Communication

Conversations in background noise    Telephone use    Group settings    Television / media

Authorization for Services and Consent

I authorize the audiologist and clinical staff to perform diagnostic and therapeutic audiologic services as indicated below. Services may include but are not limited to: otoscopic examination, pure-tone air and bone conduction testing, speech audiometry, tympanometry and acoustic reflexes, otoacoustic emissions, hearing aid evaluation and fitting, earmold impressions, and cerumen removal by manual instrumentation or suction. I understand the nature of the proposed services and hereby consent to such services.

Diagnostic hearing evaluation    Tympanometry & acoustic reflexes    Otoacoustic emissions    Hearing aid evaluation/fitting
Real-ear measurement    Cerumen removal (manual/suction)

Potential risks and complications include transient discomfort during otoscopy or tympanometry, temporary dizziness or imbalance, transient changes to tinnitus, rare risk of ear canal abrasion or infection following cerumen removal, and device fitting adjustments that may require additional visits. Expected benefits include improved diagnosis of hearing and balance disorders, improved communication function, and the provision of appropriate hearing rehabilitation. Alternatives include deferring testing, referral to other specialists, or medical evaluation prior to audiologic testing when indicated.

I understand that I may withdraw consent at any time prior to or during services by informing the clinician. Withdrawal of consent will not affect my ability to obtain future care. If treatment is provided by a minor or legally incapable patient, the undersigned certifies that they are the legal guardian or authorized representative and have authority to consent.

I authorize release of relevant audiologic and medical information to my insurance carrier, referring provider, and the following persons for purposes of treatment and billing:

Privacy, Billing, and Financial Responsibility

By signing below I acknowledge receipt of the clinic's privacy practices and consent to use and disclosure of my health information for treatment, payment, and healthcare operations as described above. I understand I am financially responsible for charges not covered by insurance, including co-payments, deductibles, services deemed non-covered, and fees for missed or late-cancelled appointments. I authorize billing of my insurance and assignment of benefits to the provider where permitted.

Cancellation policy: I acknowledge that missed appointments or cancellations made less than 24 hours before the scheduled time may incur a fee. Returned check fee or collection costs may be charged for unpaid balances. Payment policies will be explained upon request.

Acknowledgment & Certification

I certify that the information provided on this form is true and accurate to the best of my knowledge. I give permission to the audiology provider to proceed with the selected assessments and treatments. I understand that results will be discussed with me and appropriate follow-up will be recommended as clinically indicated.

Sign Now