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Patient Information

Mr.   Mrs.   Ms.  
 
  
 
 
          

Yes   No  

Employment and Student Status

  
  

Emergency Contacts

  

Primary Care Physician

 
 
 
 

Responsible Party

 
 
  

Insurance Information

 If applicable, I authorize release of medical information, necessary to process my claims and payments of medical benefits to this provider for services rendered.

Patient Responsibility Form

  1. INDIVIDUAL'S FINANCIAL RESPONSIBILITY
    • I understand that I am financially responsible for my health insurance deductible, coinsurance or non-covered service.
    • Co-payments are due at time of service.
    • If my plan requires a referral, I must obtain it prior to my visit
    • In the event that my health plan determines a service or hearing device not be a covered benefit, I will be responsible for the complete charge and agree to pay the costs of all services provided.
    • If I am uninsured, I agree to pay for the medical services rendered to me at time of

  2. INSURANCE VERIFICATION
  3. Ultimately, it is the patient's responsibility to verify their insurance benefit. To save time, please be sure to call your insurance company before your appointment.

  4. INSURANCE AUTHORIZATION FOR ASSIGNMENT OF BENEFITS
  5. I hereby authorize and direct payment of my medical benefits to Diablo Hearing Services, Inc. on my behalf for any services furnished to me by the providers.

  1. AUTHORIZATION TO RELEASE RECORDS
  2. I hereby authorize Diablo Hearing Services, Inc. to release to my insurer, governmental agencies, or any other entity financially responsible for my medical care, all information, including diagnosis and the records of any treatment or examination rendered to me needed to substantiate payment for such medical services as well as information required for precertification, authorization or referral to other medical provider.

  3. MEDICARE REQUEST FOR PAYMENT
  4. I request payment of authorized Medicare benefits to me or on my behalf for any services furnished me by or in Diablo Hearing Services, Inc. I authorize any holder of medical or other information about me to release to Medicare and its agents any information needed to determine these benefits or benefits for related services.


Signature of Patient, Authorized Representative or Responsible Party


Date

[Signature and date will be requested during office visit]

Print Name of Patient, Authorized Representative or Responsible Party


Relationship to Patient