Healthcare Hearing Center Form

Healthcare Hearing Center Form

Patient Information

Date of Birth:    Gender: Male Female Other Prefer not to say

Insurance Information

Policy Number:    Group Number:

Medical & Hearing History

History of recurrent ear infections: Yes No

Tinnitus (ringing in the ears): Yes No    If yes, describe:

Dizziness, vertigo, or balance problems: Yes No

Significant noise exposure (work, military, recreational): Yes No    If yes, describe:

Hearing-Specific Information

Problem onset:    Affected ear(s): Left Right Both

Do you currently use hearing aids or assistive listening devices? Yes No    If yes, make/model and fitted date:

Previous hearing test(s): Yes No    If yes, most recent test date:    Facility/Provider:

Consent for Evaluation, Testing, and Treatment

I authorize Healthcare Hearing Center clinicians to perform diagnostic audiologic testing and related procedures as deemed necessary for my evaluation and treatment. Such procedures may include, but are not limited to, otoscopic inspection, pure-tone air and bone conduction testing, speech audiometry, tympanometry, acoustic reflex testing, otoacoustic emissions, vestibular screening, and administration of hearing aid evaluations and fittings.

I understand the risks associated with these procedures are minimal but may include transient discomfort, brief dizziness, temporary alteration in hearing sensitivity, or ear canal irritation. I understand that the intended benefits include diagnosis of hearing and balance disorders, guidance for treatment, and recommendations for amplification or medical referral when appropriate.

I acknowledge that no guarantee has been made regarding the results of testing or the success of any recommended treatments. I understand I may decline or withdraw consent at any time prior to or during testing, and that withdrawing consent may limit diagnostic or treatment options.

By signing below I certify that I have provided accurate health information to the best of my knowledge and that I consent to the evaluations and treatments described above.

HIPAA Authorization & Release of Information

I acknowledge receipt of the practice's Notice of Privacy Practices and authorize Healthcare Hearing Center to use and disclose my protected health information for purposes of treatment, payment, and health care operations. I authorize release of diagnostic results and records to my insurance carrier, referring physician, and the following individual(s) as designated below.

This authorization will expire on:    I understand I may revoke this authorization in writing at any time, except to the extent that action has already been taken based on this authorization.

Permission to leave voicemail or appointment reminders at primary phone: Yes No

Financial Responsibility & Policies

I understand that I am financially responsible for charges not covered by insurance, including co-payments, deductibles, and services denied by my insurer. I authorize release of information necessary to process claims and assignment of benefits to the provider when applicable. I understand outstanding balances may be subject to collection activity if unpaid.

Cancellation policy: Appointments canceled without at least 24 hours' notice may be subject to a cancellation fee. Repeated missed appointments may affect my eligibility for future scheduling priority.

Patient Certification

I certify under penalty of law that the information provided on this form is true and correct to the best of my knowledge. I have read and understood the statements above concerning consent, privacy practices, and financial responsibility. I authorize the Healthcare Hearing Center to proceed with diagnostic evaluation and to release information as indicated.

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