Case History Form

Case History Form
Today's Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Patient's Social Security #:
Patient's Name:

First NameLast Name
Sex:
DOB:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Parent/Guardian Name (if patient is a child):

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone:
Format: (000) 000-0000.
Cell:
Format: (000) 000-0000.
Work:
Format: (000) 000-0000.
E-mail:
example@example.com
Patient's/Parent's Employer:
Occupation:
Spouse's Name:

First NameLast Name
DOB:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Spouse's Employer:
Occupation:
Insurance Name:
Name of Insured:

First NameLast Name
DOB:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
SS#:
2nd Insurance:
Name of Insured:

First NameLast Name
DOB:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
SS#:
Primary/PPO Physician:

First NameLast Name
Phone:
Format: (000) 000-0000.
If referred, Referring Physician:

First NameLast Name
Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Reason for referral:
May we send your doctor a note about your evaluation?
Emergency Contact:

First NameLast Name
Relation:
Phone:
Format: (000) 000-0000.
I certify that I, and/or my dependents, have insurance coverage with
and assign directly to All About Hearing, Inc. all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above-named may use my healthcare information and may disclose such information to the above-named insurance company and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services.
Signature

Acknowledgement Of Receipt Of Notice Of Privacy Practices
Patient Name:

First NameLast Name
DOB:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
I acknowledge that ALL ABOUT HEARING INC. provided me with a written copy of its Notice of Privacy Practices. I also acknowledge that I have been afforded the opportunity to read the Notice of Privacy Practices and ask questions
Authorization To Release Information To Third Party
I authorize All About Hearing Inc. to release my information to third parties, as follows:
Name:

First NameLast Name
DOB:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Relationship:
If limited, please specify:
I give All About Hearing Inc. permission to contact me regarding promotions, new technology etc.
Patient Signature:
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year

Patient Consent
CLINICAL
1. I authorize All About Hearing Inc. to perform all recommended/referred diagnostic procedures.
2. I authorize All About Hearing Inc. to complete all measures needed to make a thorough diagnosis and recommendation. I authorize that such diagnostic material may be released to third-party payors and/or other health professionals.

FINANCIAL
3. I authorize All About Hearing Inc. to furnish all information regarding my medical history, diagnosis and treatment of myself to an insurance company regarding my claim for benefits. If however, said insurer fails to meet this obligation in whole or in part, or if I am non-insured, I agree to be responsible for the fee and cost involved in my treatment. I authorize payment of medical benefits to All About Hearing Inc. and further understand that should my account have to be referred to an attorney for collection that I am responsible for all fees and costs incurred therein. I hereby authorize All About Hearing Inc. to act on my behalf in accessing medical records when and if needed

INSURANCE
4. I authorize the All About Hearing Inc. to release to staff, hospitals, health care service plans, insurance companies, self-insurers or their representatives, any and all information, records and other diagnostic material about my medical history, services rendered, or recommended treatment. I authorize All About Hearing Inc. to submit claims for payment for services rendered or pre-authorizations necessary to my insurance company on my behalf and in my name listed as “signature on file”
Patient or Guardian Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Case History Form

Medical History

Acknowledgement Of Receipt Of Notice Of Privacy Practices

Authorization To Release Information To Third Party

Patient Consent