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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




Audiology Case History – Adult




























































Acknowledgement of Receipt of Privacy Policy Notice

This document acknowledges that you have received a copy of the Notice of Privacy Practices. This document is not a contract, authorization, release, or consent form. This document will remain in your records.

(Patient), Acknowledge that I have received a copy of the Notice of Privacy Practices.

Acknowledge that I have received a copy of the Notice of Privacy Practices.

If the patient is a minor, a parent or legal guardian must sign.

If the patient is NOT a minor, but under the care of a friend, relative, or caregiver.






Notice of Policy Practices

All information that is obtained from you by this office is protected and kept confidential. Every reasonable measure to prevent unauthorized disclosure of your protected health information is practiced.

Uses and Disclosures

  • Your protected health information is accessed and used for healthcare related purposes only.
  • Your protected health information is never sold, rented, transferred, exchanged, and/or used for non-healthcare related purposes including marketing activities without your written authorization.
  • Your protected health information is disclosed to third-party entities without your written authorization for the purpose of treatment, to obtain payment for treatment and for healthcare operations.

Certain Circumstances

Your protected health information can be disclosed without your written authorization in certain limited circumstances:

  • Medical emergencies
  • In situations required by law
  • Individuals involved in your care
  • When requested by public health agency
  • When requested by a law enforcement agency

For any purpose other than treatment, obtaining payment, healthcare operations, or certain circumstances, we will ask for your written authorization before using or disclosing your protected healthcare information. If you choose to sign an authorization to disclose protected health information, you can revoke that authorization in writing at any time.

Patient Rights

  • You have the right to request in writing to inspect and/or receive a copy of your health information.
  • You have the right to request an alternate means or location to receive communications regarding your health information.
  • You have the right to request in writing to amend, correct, or delete any recorded health information within our possession.
  • You have the right to request in writing to restrict some uses and disclosures of your health information.
  • You have the right to request in writing an accounting of certain disclosures of your health information that were made by this office.

Changes to this Notice: We reserve the right to change privacy practices and the conditions of this notice at any time and without prior notice. In the event of changes, and updated notice will be posted and a copy will be made available to you.