Patient Information
Patient Full Name *
Patient Full Name
Date of Birth *
Date of Birth
Address *
Household Size *
Marital Status *
Emergency Contact
Other Information
Insurance Type *
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.
I acknowledge that I have received and reviewed the Health Insurance Portability & Accountability Act (HIPAA) policy of this office.
I understand and agree that I am ultimately responsible for the balance of my account for professional services or purchases rendered. I understand that I may request documentation to submit to my insurance or health plan on my own and that HearCare Connection will not submit this for me.
I have read all the information on this sheet and have completed the above answers, certify this information is true and correct to the best of my knowledge and hereby give my Audiology and Hearing Center permission to treat my concerns.
The FDA has determined that it is in my best health interest to have a medical evaluation by a licensed physician (preferably a physician who specializes in diseases of the ear) before purchasing hearing instruments, I have been advised by my Audiologist and Hearing Center and/or its agents about this determination and hereby waive this requirement.
By typing you, you are signing and agreeing on the above information.
Date of Signature *
Date of Signature
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
Do you have any physical and/or diagnosed mental disability?
What is your gender identity?
What is your age?
What is your highest level of education completed?
How many live in your household?
Annual Household Income
What is your Primary language
What is your Secondary Language (if any)
Do you utilize an interpreter for your medical/wellness visits?
How do you get to your medical/wellness visits?
What is your primary racial identity? (circle all that apply)
What is your Ethnicity?
I choose to provide only partial information above.
I choose to provide only partial information above.