Patient Information Form
Patient information, (Use parent/guardian information to complete reminder of this section if patient is under age of 18.)
Hearing Heath Assessment
General Information
Does having a hearing problem...
Please read carefully and sign below
I give permission to JHC to release information, verbal and written (contained in my medical record and other related information), to my insurance company, rehab nurse, case manager, attorney, employer, related health care providers, assignees and/or beneficiaries, and all other related persons, information without patient identifiers may be for quality purposes. I authorize JHC to use and release my protected health information, i.e., my contact information, for marketing related to hearing care products or services. I acknowledge that I have received and reviews the Health Insurance Portability & Accountability Act (HIPPA) policy of this office. I understand and agree that regardless of my insurance status, I am ultimately responsible for the balance of my account for professional services or purchase rendered. I have read all the information on this sheet, completed the answers, and certify this information is true and correct to the best of my knowledge, and I hereby give JHC permission to treat my concerns.