Yes No

iPhone Android Landline phone Desktop computer, laptop, tablet, or iPad FM Television Telecoil and loop systems Remote microphone (i.e., a microphone someone else wears)

I allow for voice messages from this practice to be left on any provided phone number. I allow for text messages from this practice to be sent to my mobile number. I give permission to this practice to release information, verbal or written, contained in my medical record and other related information to my insurance company, healthcare providers, assignees and/or beneficiaries and all other related persons. On occasion, The Hearing Solution sends out newsletters or birthday cards. I allow for The Hearing Solution to contact me by mail or e-mail for promotional reasons. I acknowledge that I have had the opportunity to review a copy of The Hearing Solution’s privacy notice. (Available to view on our website and in the office.) I hereby authorize all benefits for charges of examination and/or treatments requested to be paid to The Hearing Solution. Verification of insurance coverage obtained over the phone does not guarantee payment. I have read this statement and accept full financial responsibility for all medical charges incurred by my dependents or me for services rendered by The Hearing Solution. I allow the following individuals (eg. spouse/family members/caregivers) to be allowed access to my information regarding my hearing and ongoing treatments for the duration of my care, unless The Hearing Solution is notified otherwise: