I give permission to my Audiology and Hearing Center to release information, verbal and written, contained in my
medical record and other related information, to my insurance company, rehab nurse, case manager, attorney, employer,
related healthcare providers, assignees and/or beneficiaries and all other related persons. Information without patient
identifiers may be used for quality purposes, research, or reports to funders.
Thank you for taking the time to complete the following survey. The information collected will be confidential (see our
HIPAA disclosure). The information obtained below will not be used in determining eligibility for our services, but may be
used strictly in the collection of general data and/or reporting for the nature of and scope of our work as a nonprofit
organization. This information helps us in identifying disparities in our community and to help in making informed quality
improvement efforts. Because our organization is nonprofit, we rely on public funding sources so that we may continue
to provide services and hearing healthcare to the underinsured, low-income, and uninsured residents of our community.
By completing our survey, you help us in determining the need and in helping us to better provide these services to you
and others in our community. Thank you for your time