Patient Registration Form

Patient Information

Title: Mr. Mrs. Ms.

*Date of Birth:

*First Name:

*Last Name:

*Preferred Name:

*Address:

*MI:

*City:

*State:

*Zip Code:

*Home Phone:

*Cell Phone:

*Email Address:

*Marital Status:

*Is Spouse a patient?
Yes No

*Spouse Name:

Employment and Student Status

Employment Status: Full Time Part Time Not Employed Self Employed Retired Active Military

Employer:

Occupation:

Emergency Contacts

*Name:

*Relationship to Patient:

*Address:

*Phone Number:

*City:

*State:

Primary Care Physician

*Primary Physician:

*City:

*Phone:

*Referring Physician:

*City:

*Phone:

*Whom may we thank for referring you to our office?

Responsible Party

Name:

Address:

City:

State:

Zip Code:

Home Phone:

Cell Phone:

Relationship to Patient:

Insurance Information

*Insurance Co. Name

*Phone Number:

*Primary Insurance Subscriber:

*ID Number:

*Group Number:

*Relationship to Patient:

*Subscribers Date of Birth:

Please click if you have no Secondary Insurance

*Insurance Co. Name

*Phone Number:

*Secondary Insurance Subscriber:

*ID Number:

*Group Number:

*Relationship to Patient:

*Subscribers Date of Birth:

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

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

INSURANCE VERIFICATION

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.

INSURANCE AUTHORIZATION FOR ASSIGNMENT OF BENEFITS

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.

AUTHORIZATION TO RELEASE RECORDS

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.

MEDICARE REQUEST FOR PAYMENT

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

*What is the reason for your appointment? (check all that apply)

Gradual increase in hearing difficulty Sudden hearing loss Dizziness/Vertigo Tinnitus (Ringing and Buzzing) Routine screening Annual re-test; known hearing loss Hearing aid consultation Other

*Who referred you?

Doctor

Other

*Have you previously had a hearing test?

Yes - When?

If yes, please bring a copy to your appointment

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.

*I, (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.

Parent or legal Guardian

Relationship to Patient

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

Relationship to Patient

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.