Clone of OFFICE VERSION - Intake Form

Language

English (United States)
Español
Português
Français
Deutsch
Italiano

Bethesda Audiology Center Intake Form

Please complete this form to help us provide you with the best audiology service. We use best practices, standard protocols, and policies to ensure consistent care with all of our patients.
How did you find us?

Other
Please read this information carefully before continuing.
Specifically, "how you found us?" (i.e. - name of physician, Google, Insurance, Facebook, etc)
Patient Full Name

First NameLast Name
Preferred Name (Nickname)
How would you preferred to be addressed? For example, "John" as opposed to "Jonathan" or "Sam" as opposed to "Samantha"
Title/Honorific
Title/Honorific description
Please describe your specific title.
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Marital Status

Other
Phone Number 1 (Primary)
Please enter a valid phone number.Format: (000) 000-0000.
Phone Number 1 (Primary - TYPE)
DO NOT CALL
Phone Number 2 (Secondary)
Please enter a valid phone number.Format: (000) 000-0000.
Phone Number 2 (Secondary - TYPE)
Email Address
example@example.com (If no email, please put, "n/a")
DO NOT EMAIL
Parent/Guardian Information (for patients who are minors)
Is the PATIENT a minor?
Relationship to Patient

Other
Parent/Guardian Name #1

First NameLast Name
Parent/Guardian #1 Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent/Guardian #1 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian #1 Email
example@example.com (If no email, please put, "n/a")
Is the parent/guardian's address the same as the patient's information?
Parent/Guardian #1 Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Would you like to add a second parent/guardian?
Parent/Guardian Name #2

First NameLast Name
Parent/Guardian #2 Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent/Guardian #2 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian #2 Email
example@example.com (If no email, please put, "n/a")
Is the parent/guardian's address the same as the patient's information?
Parent/Guardian #2 Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
I hereby authorize Independence Hearing Group, LLC (doing business as Bethesda Audiology Center) to provide evaluation and treatment services for the above-named patient. Under state law, individuals under the age of 18 are considered minors. Parents/guardians are asked not to leave the clinic while a minor under the age of seventeen is being treated at this clinic. Parents/guardians are solely responsible for determining how their children may safely travel to the clinic.
Authorized/Emergency Contact Information

Please provide details for your authorized or emergency contact.
Do you have an authorized or emergency contact that you would like to use on file?
Authorized/Emergency Contact Name #1

First NameLast Name
Authorized/Emergency Contact Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Authorized/Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Authorized/Emergency Contact Email Address #1
example@example.com (If no email, please put, "n/a")
Is Authorized/Emergency contact person RESPONSIBLE FOR BILLING?
Permission to SHARE BILLING INFORMATION with this person?
Permission to SHARE HEALTHCARE INFORMATION with this person?
Do you have a SECOND authorized or emergency contact that you would like to use on file?
Authorized/Emergency Contact Name #2

First NameLast Name
Authorized/Emergency Contact Address #2

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Authorized/Emergency Contact Phone #2
Please enter a valid phone number.Format: (000) 000-0000.
Authorized/Emergency Contact Email Address #2
example@example.com (If no email, please put, "n/a")
Permission to SHARE BILLING INFORMATION with this person?
Permission to share your BILLING INFORMATION with this person?
Permission to share your HEALTHCARE INFORMATION with this person?

Insurance Information
Primary Insurance Coverage
Insured Name (Patient)

First NameLast Name
Insurance Company
Medicare, Blue Cross Blue Shield, Aetna, United Healthcare, etc.
Insurance/Member ID Number
Insurance Group Number
Take photo of front of card (you can also bring the card to the office and we can scan it for you)
Take photo of back of card (you can also bring the card to the office and we can scan it for you)
Policy Holder (ONLY IF DIFFERENT than the insured/patient)

First NameLast Name
Is the contact information for the policy holder the SAME as the PATIENT?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Subscriber Phone Number
Format: (000) 000-0000.
Secondary Insurance Coverage
Insurance Company
Medicare, Blue Cross Blue Shield, Aetna, United Healthcare, etc.
Insurance/Member ID Number
Insurance Group Number
Take photo of front of card (you can also bring the card to the office and we can scan it for you)
Take photo of back of card (you can also bring the card to the office and we can scan it for you)
Policy Holder (ONLY IF DIFFERENT than the insured/patient)

First NameLast Name
Is the contact information for the policy holder the SAME as the PATIENT?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Subscriber Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Tertiary Insurance Coverage
Insurance Company
Medicare, Blue Cross Blue Shield, Aetna, United Healthcare, etc.
Insurance/Member ID Number
Insurance Group Number
Take photo of front of card (you can also bring the card to the office and we can scan it for you)
Take photo of back of card (you can also bring the card to the office and we can scan it for you)
Policy Holder (ONLY IF DIFFERENT than the insured/patient)

First NameLast Name
Is the contact information for the policy holder the SAME as the PATIENT?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Subscriber Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Release of Information
I authorize the release of the following information to:
Doctor, facility, individual to share the information, etc.
Designated Recipient - Address, Phone #, and/or Fax
Contact information
Scope of Release (select all that apply)
Do you have another recipient you would like to share information with?
I authorize the release of the following information to:
Doctor, facility, individual to share the information, etc.
Designated Recipient - Address, Phone #, and/or Fax
Contact information
Scope of Release (select all that apply)
CONSENT TO TREAT ------ I hereby authorize Independence Hearing Group, LLC (doing business as Bethesda Audiology Center) to provide evaluation and treatment services for the above-named patient. Additionally, if the clinician(s) and/or staff determine that the patient is in need of emergency medical care, the clinic is hereby authorized to obtain the care required, at the expense of the undersigned.
PATIENT HIPAA CONSENT --- I understand that I have certain rights to privacy regarding my protected health information according to the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize the clinic to use and disclose my protected health information for the purpose of: 1) Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment) and Referral Authorization Requests 2) Obtaining payment from insurance or third party benefit plans and benefit eligibility inquiries 3) The day-to-day healthcare operations of the clinic such as quality assessments and provider certifications and other transactions for which HHS has established standards under the HIPAA Transactions Rule. I acknowledge the HIPAA Consent statement.
INSURANCE AND PAYMENT --- I authorize the clinic to provide medical treatment and file my insurance and third-party benefit claims. I authorize payments of medical benefits to be paid directly to the clinic. I understand that insurance coverage is ultimately the patient’s responsibility, including determining in-network and out-of-network status and verifying specific benefits. While the clinic may provide verification of benefits as a professional courtesy, the patient remains fully responsible for all services and charges not paid for by their insurance company or third-party benefit plan.I accept full responsibility for all charges in the event that I have no insurance or third-party benefits. Charges 30 days past due are subject to late fees.

Audiologic History
Have you had a hearing evaluation in the last 12 months?
Primary reason(s) for visit

Other
How does your hearing hold up during quiet, one-on-one chats?
How does your hearing hold up when you are out and about in social settings, group chats, restuarants, family gatherings, etc.?
How is your TV listening going? Or does someone else claim the volume is too loud?
Would your family member(s) and/or friend(s) agree or disagree with YOUR VIEW of how well you may hear? Please describe below.
Or stated differently, does a family member have a different viewpoint of how well you hear or not? Please describe.
Is hearing the same in both ears?
If you, or your family member(s)/friend(s), feel there MAY be a hearing loss, how was the onset?
Do you experience any of the following? If you answer "yes" to any option, please describe below.
If the answer is "other" or an answer you marked as "yes" to the section above needs more of an explanation, please describe it here.
Medical History (check all that apply)
If the answer is "other" or an answer you marked as "yes" to "Medical History" needs more of an explanation, please describe it here.
Do you take blood thinners?
Have you used hearing aids previously?
Please describe, as best you can, "name of hearing aid manufacturer (i.e. - Widex, ReSound, Signia, Phonak, etc)," approxiamately how many years, where you purchased the devices, and any other information regarding your current or previous devices.
In unknown, please make your best guess.
Do you use a pace maker?
"Do you experience tinnitus? (Pronounced /tin-EYE-tus/, or /tin-uh-tus/—we answer to both -- but, it, unfortunately, sounds like "ringing, buzzing, crickets, cicadas, water, whooshing, etc)"
If you do have the above sounds in your ear(s), when or how often do you hear them?
Which ear do you hear the tinnitus?
"How would you rate how loud or bothersome the ringing is?"
Do you currently take any medications?
Take Photo (you can also bring the medication list to the office and we can scan it for you)
If yes, please list your medications
Do you have any allergies?
Please list any allergies
Is there anything else you would like us to know?
Name
Please type your name as the authorized signatory
Signature (Authorized Signatory)

Please sign your name as best you can.
Should be Empty: