Patient Name

    Patient Age

    Date

    Approximate date of last hearing test:

    Chief Complaint:

    How long have you noticed this difficulty?

    Primary reason for visit


    How important is it for you to improve how you hear, understand, or communicate with others RIGHT
    NOW (mark on the line)

    11

    Have you ever worn a hearing aid?

    Do you wear hearing aids now? Yes or No

    In which ear do you wear hearing aids now?

    Is this problem due to a work-related injury/exposure?

    Date of Injury

    Injury Explain

    Do you feel your hearing is changing?

    Any drainage from the ear within the past 90 days?

    Do you have any noise or ringing in your ears?

    In which Do you have any noise or ringing in your ears?

    Have you ever been exposed to loud noise, either recently or in the past?

    If Yes please mark all that apply

    Have you ever had any ear surgery?

    Is there a history of hearing loss in your family?

    Do you have a history of chronic ear infections?

    If Yes

    How much: nicotine

    Alcohol (drinks per day/wk)

    Caffeine

    Aspirin used

    Have you experienced chronic or acute dizziness, light-headedness, balance problems, falls, or vertigo?

    Do you take any prescription medications on a regular basis? (WE NEED ALL INFORMATION COMPLETED)

    Please check any of the following that you currently have or have had in the past:


    How confident are you in your own ability to use and take care of hearing aids if they are recommended? (mark on the line)0 (Not at all confident) (Extremely confident) 10

    1
    5

    In what situations would you most like hearing aids to help you (if recommended):

    Select all that apply:

    I hereby consent to testing by the audiologist(s) of Audiology Providers, P.C. or Hearing Aids PLUS, P.C.. This consent also includes consent to take a medical history, perform diagnostic and/or audiologic testing, and when applicable: remove cerumen, and/or make ear impressions.

    Name

    Address:

    Employer:

    Spouse Details:

    Only needed if spouse is insurance policy holder/or secondary

    In case of emergency, contact

    Primary Care Physician

    Would you like a copy of your test results forwarded to your physician? (If so, please sign below)

    How did you hear about us?

    If applicable, please provide the name of the person

    In order for us to file your insurance claim for you, the following MUST be signed:

    I authorize the release of any medical and/or other information necessary to process my medical claim. I also request that payment of government benefits, either to myself or to the party who accepts assignment.

    Further, I authorize payment of medical benefits to be made directly to Audiology Providers, P.C. or Hearing Aids PLUS, P.C. for services rendered. This authorization shall remain in effect until otherwise stated, in writing, by myself.

    Patient/Parent/Guardian Signature

    Date

    Medicare Patients Certification (Medicare Only)

    I request payment of authorized Medicare benefits to be made to Audiology Providers, P.C. for any services rendered. I authorize any holder of medical information about me to be released to the Health Care Financing Administration and its agents and information needed to determine these benefits or related services to pay the claim. If there are any other insurance carriers, my signature authorizes releasing of information. In Medicare assigned cases, the provider agrees to accept the charge determination of the Medicare carrier as the full charge and the patient is responsible for only the deductible, coinsurance, and the non-covered services. Coinsurance and the deductible are based upon the charge determined by the Medicare carrier.

    Patient/Parent/Guardian Signature

    Date

    Responsibility of Non-Covered Services

    I have been informed that the services provided to me while I am a patient of Audiology providers, P.C. or Hearing Aids PLUS, P.C. are furnished only at my direction or at the direction of my hearing health care professional and that Audiology Providers, P.C. or Hearing Aids PLUS, P.C. makes no representations concerning the medical necessity or reasonableness of such procedures or services. The decision as to the necessity or reasonableness of any procedure or service is made by the appropriate state medical program, insurance company, or its health insurance agent. I understand that I am responsible for payment for any procedure, service, or product which were provided to me at my request by my hearing health care professional and which are determined not to be reasonable and medically necessary as required by the appropriate government, or insurance medical program.

    The undersigned patient recognizes that (he/she) remains financially responsible to Audiology Providers, P.C. and/or Hearing Aids PLUS, P.C. for charges not paid or covered by said insurers. Each of the undersigned insureds also hereby authorize any overpayment to Audiology Providers, P.C. and/or Hearing Aids PLUS, P.C. regarding this visit which would otherwise be payable to said undersigned to be applied and credited against any previous balance due Audiology Providers, P.C. or Hearing Aids PLUS, P.C. for which said undersigned is the responsible party.

    I irrevocably assign to Audiology Providers, P.C. or Hearing Aids PLUS, P.C. all rights, title, and interest in benefits payable out of any third party action against any other person, entity, or insurance company, or out of recovery under the uninsured motorist provisions or the medical payment provision of any insurance policy (ies) or any other insurance policy (ies) under which I may be entitled.

    I the undersigned guarantor, hereby guarantee full and prompt payment to Audiology Providers, P.C. or Hearing Aids PLUS, P.C. of all charges made as a result of services rendered the above named patient during this visit. I agree to pay for said charges upon the failure of said patient, any responsible insurer or any other person or firm to pay same when due. The patient is responsible for any legal or court costs required in the collection of any unpaid accounts.

    Patient/Parent/Guardian Signature

    Date

    All Patients Please Read and Sign

    Your insurance policy is a contract between you and your insurance company. We cannot guarantee payment of your claims or accept responsibility for negotiating claims with your insurance company. As a courtesy, we will be happy to help you determine the coverage you have available.

    I hereby assign all medical benefits to include major medical benefits to which I am entitled, private insurance, and any other health plans to Audiology Providers, P.C. and/or Hearing Aids PLUS, P.C. A photocopy of my insurance card and a copy of my driver's license are to be considered as valid and original.

    I am financially responsible for all charges whether or not paid by my insurance company.

    I hereby authorize Audiology Providers, P.C., and/or Hearing Aids PLUS, P.C. to release all information necessary to secure the payment. If insurance pays only a portion of the bill or fails to make payment to Audiology Providers, P.C. and/or Hearing Aids PLUS, P.C. within 90 days, I will be responsible for payment of balance in full at that time.

    Patient/Parent/Guardian Signature

    Date

    PRIVACY NOTICE

    We understand that medical information about you and your health is personal. We are committed to protecting the confidentiality of your medical information. As part of our routine operations, we create a record of the care and services you receive. We need this record to provide you with quality care and to comply with certain legal requirements.

    Federal law requires us to 1) make sure that medical information that identifies you is kept private; 2) give you this notice of our legal duties and privacy practices; and 3) follow the terms of the notice that is currently in effect.

    If the practices described in this notice meet your expectation, there is nothing you need to do. If you have any questions regarding this Privacy Notice, please contact our Privacy Officer, Jamie Holden at 214.705.9994.

    All employees of our company follow the terms of this notice. Some employees may share medical information with each other for purposes of treatment, payment or healthcare operations as described in this notice.

    How We May Use and Disclose Medical Information About You

    • For Treatment - We may use medical information about you to provide you with products or services. We may disclose medical information about you to other employees in order to coordinate the different products and services we offer. We may also disclose medical information about you to people outside the facility who may be involved in your medical care, such as family members or others we use to provide services that are part of your care.

    • For Payment - We may use and disclose medical information about you so that your treatment, products, and services you received from us may be billed to and payment may be collected from you, an insurance company, or third party. For example, we may need to give your insurance company information about your hearing aids in order for claims to be filed for payment to our company or reimbursement to you. We may aho tell your health care plan about treatment or products you are going to receive to obtain prior approval or to determine coverage. For Healthcare Operations -We may use and disclose medical information about you for our facility operations. These uses and disclosures are necessary to run the facility and make sure that all of our patients receive quality care. For example, we may use medical information from a number of patients to review our products and services to see if we need to make changes, or evaluate staff performance.

    • Appointment Reminders - We may use and disclose medical information to contact you as a reminder that you have an appointment at our facility.

    • Treatment Alternatives - We may use and disclose medical information to tell you about or recommend products or services that may be of interest to you.

    • Health-Related Benefits and Services - We may use and disclose medical information to tell you about health related benefits or services that may be of interest to you.

    • Individuals Involved in Your Care or Payment for Your Care - We release medical information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care.

    • As Required by Law - We will disclose medical information about you when required to do so by federal, state, or local law. We may also release medical information if asked to do so by law enforcement officials, such as in response to a court order or subpoena.

    • Health Oversight Activities - We may disclose medical information to a health oversight agency for activities authorized by law. For example, we may disclose information to the Texas Department of Health relating to an audit or for licensure.

    Your Rights Regarding Medical Information About You

    You have the following rights regarding medical information about you. To exercise any of these rights, you must submit the request in writing to: Audiology Providers, P.C., Attn: 7000 Parkwood Blvd, Suite G100, Frisco, TX 75034

    • Right to Inspect and Copy - You have the right to inspect and obtain a copy of medical information that may be used to make decisions about your care. If you request a copy of the information, we may charge a fee of $10.00 for the costs of copying, mailing, and administration. We may deny your request to inspect and copy in certain very limited circumstances.

    • Right to Amend - If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. As part of your written request to amend, you must provide a reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. We may also deny your request for an amendment if it is not in writing or does not include a reason to support the request. We may also deny your request if you ask us to amend information that: was not created by us, is not part of the medical information kept by our facility, is not part of the information which you would be permitted to inspect or copy, or if you ask us to amend information that is accurate and complete.

    • Right to an Accounting of Disclosures - This is a list of the disclosures we made of medical information about you. Your request must state a time period and may not include dates before February 26, 2003. The first list you
      request in a 12-month period will be free. For additional list, we may charge you for the costs of providing the list.
      We will notify you of the cost involved and you may choose to withdraw or modify your request before any costs are incurred.

    • Right to Request Restrictions - You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or healthcare operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care, like a family member, or a friend. Written requests for restrictions must tell us 1) what information you want to limit; 2) whether you want to limit our use, disclosure or both; and 3) to whom you want the limits to apply. We are not required to agree to your request.

    • Right to Request Confidential Communications - You have the right to request that we communicate with you about medical matters in a certain way or at certain locations, such as to contact you at home, and not at work. Written requests for confidential communications must specify how or where you wish to be contacted. We will not ask you the reason for your request. We will accommodate all reasonable requests.

    Changes to this Notice

    We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have as well as any information we receive in the future. We will post a current copy of this notice in the facility.

    Complaints

    If you believe your privacy rights have been violated, you may file a complaint with Audiology Providers, P.C., or with the Secretary of the Department of Health and Human Services. To file a complaint with our company, submit your written complaint to: Audiology Providers, P.C., Attn: HIPAA Contact, 7000 Parkwood, Suite G100 Address

    Acknowledgement

    We may ask to acknowledge receipt of this Privacy Notice. Should you decline to acknowledge receipt of this notice, we may record in your medical records the date the notice was given to you.

    Patient/Parent/Guardian Signature

    Date