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”