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Welcome! Your journey to better hearing starts here.
Welcome! Your journey to better hearing starts here.
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Patient Intake Form
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    • Male
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    • Single
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    The following questions are about your medical history

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    Are you experiencing any of the following symptoms?

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    The following questions are about your hearing

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    Please tell us what is important to you regarding hearing aids if you were to need them...

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  • 63

    FINANCIAL POLICY

    Unless otherwise indicated, payment on your account (if any) is due at the time services are rendered. We will clearly explain to you any charges prior to rendering any services. You will also be informed prior to us rendering services if we are contracted with your insurance. When applicable, all services and products not paid for by your insurance are your responsibility. Many insurance companies will reimburse the insured (you) directly, in this case we can supply you with the necessary information so that you can submit a claim, otherwise when contracted we will submit the claim.

    We highly recommend that you verify benefit coverage with your insurance to ensure that you receive the same information from them as we have. Mt. Hood Hearing cannot be held responsible for any unpaid claims by your insurance company to you.

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    In order to keep your health information confidential, we ask you to designate with whom the staff at Mt. Hood Hearing may discuss test results, hearing aid, insurance and/or financial information.

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    ie: Daughter
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    ie: Daughter
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    ie: Daughter
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