REGISTRATION FORM

Name of secondary insurance (if applicable):

If you are not the policy holder please provide the following information:

IN CASE OF EMERGENCY (not living at same address)

Ihereby consent to treatment as deemed necessary or advisable in the diagnosis and treatment of my hearing health care. I authorize Liberty Hearing Centers & Dr. John P. Weigand AUD P.C to submit claims to my insurance company. I request that payment of authorized benefits be made either to me, or on my behalf to Liberty Hearing Centers & Dr. John P. Weigand AUD PC., for any services rendered to me by the physician. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits payable for related services. I understand that I must notify the physician's office if I decide to join or change my insurance plan. The proper referral with co-pay (if required) must be provided on the day medical services are rendered. Referrals are not retroactive. I understand that if I fail to notify the physician's office of my disenrollment or changes in the status of any eligibility within the plan, then I will be responsible for any outstanding balance on my account due to that change. I have read and understand the above text.

AUTHORIZATION TO RELEASE INFORMATION

I hereby authorize any physician or other person who has attended or examined me or my family members to furnish the insurance carrier with respect to any illness or injury, medical history or consultation, prescription or treatments and copies of all medical records. A photo copy of this authorization shall be considered as valid as the original.

You are entitled to our Notice of Privacy Practices describing how your health information can be used and disclosed by Liberty Hearing Centers & Dr. John P Weigand AUD PC. (LHC), and how you can obtain access to and control this information. By signing below, I acknowledge that I may request a copy of these forms.

Please identify family members, relatives or close personal friends that we may share your health information with who are involved in your care or payment for that care. We may also notify a family member, personal representative or another person responsible for your care about your location and general condition, or about the unfortunate event of your death.

I,knowing that I require Medical care or a course of treatment, consent to diagnostic treatment procedures by Liberty Hearing Centers & Dr. John P. Weigand AUD PC., or assistants or person(s) they designate. Iam aware that the practice of medicine is not an exact science. No guarantees have been made to me about the benefits or results of procedures and treatments authorized above. Ifurther consent to the use of patient information for training and education purposes by Liberty Hearing Centers & Dr. John P. Weigand AUD PC., and their physicians; at the same time, Liberty Hearing Centers & Dr. John P. Weigand AUD PC., are to protect my identity. By signing this consent form, I hereby authorize the provider and its medical staff to use and disclose my personal health information, as necessary for the purposes of obtaining medical treatment, enabling the provider and its staff to obtain payment for such treatment and for the normal business operations of the provider. I have read and understood this form and I understand that I may ask for further explanations at any time.

Medical Conditions (Please circle all that apply):

Are you experiencing or have you ever experienced any of the following? (Please circle all that apply):

Tinnitus/Ringing Left Right Both

Have you ever worn a hearing aid?