The Hearing Solution - New Cochlear Implant Patient Form

Notice of Privacy Practices and Right to Bill
Please review and check the following boxes:

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:
(ex. spouse/caregivers/family members)
Signature
Date

MonthDayYear
*

I have read the above form and acknowledge receipt of all information
Should be Empty:

Rows	Yes	No
Ear pain
Pressure or fullness in the ear(s)
Ear infection(s)
Drainage from your ear(s)
A recent head trauma
Ringing/buzzing/tinnitus in your ears
Sudden/progressive hearing loss in the last 90 days

Rows	No Difficulty	Slight Difficulty	Moderate Difficulty	Very much difficulty	Not Relevant
One on one conversations
Conversations in small groups
Conversations in large groups
Outdoors
Concerts/Theaters
Place of worship/lecture halls
Watching TV
In a car
Landline Phone
Cell Phone
Restaurants

New Patient History Form

Cochlear Implant History

Health Concerns and Changes

Optional: Hearing Performance

Notice of Privacy Practices and Right to Bill