New Patient Paperwork

HIPAA Notice

This form complies with the Federal Health Insurance Portability and Accountability Act (HIPAA). This is a secure form; the information that you enter here will be seen only by the staff of our practice.

Directions: fill out all applicable fields and submit the form. We will contact you if there are any concerns or errors with your submissions.

* Required Fields

HIPAA Notice of Privacy Practices

This form is transmitted securely — your responses are encrypted into a password-protected file for our staff and are never stored on our servers.

This acknowledges that you have received and reviewed our Notice of Privacy Practices, which describes how your protected health information (PHI) may be used and disclosed, and how you can access this information. Our current Notice is posted in our reception area, and amended notices are available at each appointment. Your PHI is shared only with the physicians listed on your intake form and is used to obtain payment for services. By signing below, you may also consent to receive marketing communications about hearing health products and services; the practice may receive financial remuneration from a manufacturer for such communications, and you can opt out at any time.

Patient Name*

Patient Address*

Signing As*

Patient (signing for self)

Parent/Guardian of Minor Patient

Guardian/Conservator of an Incompetent Patient

Name (of person signing)*

Phone Number*

Email Address for Updated Notice (optional)

I acknowledge that I have received and reviewed the Notice of Privacy Practices described above.*

I also consent to receive marketing communications regarding hearing health products and services as described above.

Signature (type full name)*

Date*

HIPAA Notice

HIPAA Notice of Privacy Practices

Better Hearing Changes Everything