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Patient Intake Form

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Why have you decided to get your hearing tested at this time?
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History of Communication Problems

Please answer these questions. They will help your Audiologist better understand your needs. It may also help if you can talk these over with your family and friends.

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8. Your needs and wants are important to us, so please rank the following in order of most importance regarding purchasing a hearing aid: (1-most important, 6-least important)
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Patient Privacy Notice (HIPAA)

This notice describes how your healthcare information obtained in this practice will be used for the purpose of diagnosing and treating hearing disorders as required by the Privacy Regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Please review it carefully.

- Your personal information will be disclosed only for the purpose of treatment, insurance billing and healthcare operations (such as ordering a hearing instrument). Disclosures of your personal health information for any use other than the above-mentioned purposes will require your written authorization; except as required by law, (i.e. judicial proceedings, law enforcement, public health emergencies).

- Authorized disclosures by you of your healthcare information for uses other than payment, treatment, and healthcare operations will be maintained in your chart. You may request to see a list of these disclosures.

- Our office routinely makes reminder telephone calls to confirm appointments. If we reach an answering machine, we will leave a message with our practice name and the time and date of your appointment. If you do NOT want us to leave you a message, please contact the front desk.

- Any information you send to us (pictures, stories, letters, biographies, thank-you notes, etc.) becomes the exclusive property of Waterville Audiology. We reserve the right to use non-identifying information about our clients for fundraising and promotional purposes that are directly related to our mission. Patients will not be compensated for use of this information. Patients may specifically request, in writing, that no information be used for promotional purposes; however, we are not responsible for purchased mailing lists to random databases. We reserve the right to release information regarding your treatment to your physician and/or referring agency. We also retain the right to call you for follow-up services.

- You have the right to restrict our use and disclosure of your personal information. You may request to make changes and amendments at any time.

Your signature below indicates you have been given an opportunity to read Waterville Audiology’s Notice of Privacy Practices. Please use your mouse or finger, if on a phone, to sign in the box below.

Please Sign
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I authorize copies of the reports to be released to the following friend/family member/POA/Guardian:
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