I permit Healthy Hearing and Balance to release information, verbal and written, that may be necessary for my continued
medical care, contained in my medical records and other documents, to those parties identified on the contact/release
of information or my insurance company for the processing of a healthcare claim. Information that does not identify me
as the patient may be used for quality purposes.
• I acknowledge that I have reviewed the Health Insurance Portability & Accountability Act (HIPAA) policy for this office and a copy is available to me, upon request.
• I understand and agree that regardless of my insurance status, I am ultimately responsible for my account balance for
professional services rendered or purchases made. I understand that my health insurance company may deny
payment for services or pay less than expected. If my health insurance company denies payment, I agree to be
personally and fully responsible for payment in full upon receipt of the bill. Upon request, a claim form can be
provided for you to appeal with your insurance. I also understand that if my health insurance does make
payment for services, I will be responsible for any co-payment, deductible, or coinsurance that applies.
If it is determined that hearing aids would be beneficial for your hearing loss, we will contact your insurance to
obtain possible coverage. The quote of benefits you are provided does not guarantee payment or verify
eligibility but is based on information obtained from your insurance company. Payment of benefits is subject to
terms, conditions, limitations, and exclusions of the member’s contract at the time of service. We encourage you
you to contact your insurance company to verify as well.
• The patient or their representative is responsible for obtaining any needed referrals.
• I hereby authorize direct payment of healthcare benefits to Healthy Hearing and Balance for services rendered.
• I hereby authorize Nancy E. Hart, Au.D., FAAA, CCC-A and Elizabeth Dolan, AuD, FAAA, CCC-A to remove Cerumen
(earwax) as allowed by the state Board of Examiners for Audiologists, Hearing Aid Dispensers, and Speech-Language
Pathologists.
• There will be a $75.00 charge for Hearing Aid appointments if the Hearing Aids were not purchased from our practice.
There may be additional service fees if the Hearing Aids are out of warranty and/or if additional services are needed.
• I permit to receive written correspondence regarding appointment reminders, special events, or new technology from
Healthy Hearing and Balance. I understand that my private information will not be sold, shared, or rented to outside
parties in ways different from what is disclosed in this statement.
• I have read all the information on this sheet, have provided the requested information, certify this information is true and
correct to the best of my knowledge, and hereby give my hearing healthcare professional permission to treat my condition.