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Patient Registration Form

Please complete the Patient Registration Form making sure all required fields by an asterisk are marked.


Primary Care Doctor's Info

NameAddressCityStateZip
PhoneEmail

1. At this time do you have any of the following:

YesNoYesNo
Acute or recurring dizziness? Diabetes?
Sudden or recent hearing loss? Allergies?
Ear drainage? Skin problems?
Ear pain? Punctured eardrum?

2. Have you ever seen a physician about any ear problem?

Have you ever seen a physician about any ear problem? Yes No

3. If yes, about how long ago did you last see a physician concerning your ears? Yrs

  1. Nature of problem:
  2. Was surgery performed? Yes No
4. Do you want us to contact your physician about your hearing? Yes No
5. Have you ever used a hearing aid? Yes No
6. Do you suffer from tinnitus(head noise/ringing in the ear) Yes No
7. In which situations do you have difficulty hearing? Yes No

Insurance Information:

Private: Medicaid # Medicare # Other

* Most Private Insurances do not cover hearing aids, please check directly with your insurance carrier

How did you hear about us?

Referred By:

Doctor
Friend
Newspaper
Mailing
Other

Medical Disclaimer/Medical Waiver: The purchaser has been advised at the outset of his relationship with the hearing aid dispenser that any examination or representation made by a licensed hearing aid dispenser in connection with the practice of fitting and selling of this hearing aid, or hearing aids, is not an examination, diagnosis, or prescription by a person licensed to practice medicine in this State, or by certified audiologist and therefore must not be regarded as medical opinion.

HIPAA: By submitting this form you are acknowledging that you have read the HIPAA Privacy Act Agreement.

At Hearing Life, We Care About Your Privacy

NOTICE OF PRIVACY PRACTICES

 

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS
THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

 

OUR PLEDGE REGARDING MEDICAL INFORMATION
The privacy of your medical information is important to us. We understand that your medical information is personal and we are committed to protecting it. We create a record of the care and services you receive at our practice. We need this record to provide you with the quality care and to comply with certain legal requirements. This notice will tell you about the ways we may use and share medical information about you. We also describe your rights and certain duties we have regarding the use and disclosure of medical information.

OUR LEGAL DUTY
The law requires us to:

  1. Keep your medical information private.
  2. Give you this notice describing our legal duties, privacy practices, and your rights regarding your medical information.
  3. Follow the terms of the notice that is now in effect.

We have the right to:

  1. Change our privacy practices and the terms of this notice at any time, provided that the changes are permitted by law. 
  2. Make the changes in our privacy practices and the new terms used of our notice effective for all medical information that we keep, including information previously created or received before the changes.

Notice of Change to Privacy Practices
Before we make an important change in our privacy practices, we will change this notice and make the new notice available upon  

request.

 

 

USE AND DISCLOSURE OF YOUR MEDICAL INFORMATION
The following Section describes different ways that we use and disclose medical information. Not every use or disclosure will be  

listed. However, we have listed all of the different ways we are permitted to use and disclose medical information.

 

 

WE WILL NOT USE OR DISCLOSE YOUR MEDICAL INFORMATION FOR ANY PURPOSE NOT LISTED BELOW, WITHOUT YOUR SPECIFIC WRITTEN AUTHORIZATION. YOU MAY REVOKE ANY SPECIFIC WRITTEN AUTHORIZATION BY WRITING TO US AT ANY TIME.

 

FOR TREATMENT: We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other people who are taking care of you.

We may also share medical information about you to your health care provider to assist them in treating you.

FOR PAYMENT: We may use and disclose your medical information for payment purposes.

 

FOR HEALTHCARE OPERATIONS: We may use and disclose your medical information for our health care operations. This may include measuring and improving quality, evaluation of the performance of employees, conducting training programs, and getting the accreditation, licenses and credentials we need to serve you.

 

ADDITIONAL USES AND DISCLOSURES: In addition to using and disclosing your medical information for treatment, payment and health care operations, we may use and disclose medical information for the following purposes.

 

NOTIFICATION: Medical information to notify or help to notify a family member, your personal representative, or another person responsible for your care. We will share information about your location, general condition, or death. If you are present, we will get your permission, if possible, before we share, or give you the opportunity to refuse permission. In case of an emergency, and if you are not able to give or refuse permission, we will share only the health information that is directly necessary for your health care, according to our professional judgment. We will also use our professional judgment to make decisions in your best interest about allowing someone to pick up medicine or prescriptions, x-rays or medical information about you.

 

RESEARCH IN LIMITED CIRCUMSTANCES: Medical information for research purposes in limited circumstances where the research has been approved by a review board that has reviewed the research proposal and established protocols to ensure the privacy of medical information.

 

FUNERAL DIRECTOR, CORONER, and MEDICAL EXAMINER: To help them carry out their duties, we may share the medical information of a person who has died with a coroner, medical examiner, funeral director, or an organ procurement organization.

 

SPECIALIZED GOVERNMENT FUNCTIONS: Subject to certain requirements, we may disclose or use health information for military personnel and veterans, for nation’s security and intelligence activities, for protective services for the President and others, for medical suitability determinations for the Department of State, for corrections institutions and other law enforcement custodial situations, and for government programs providing public benefits.

 

COURT ORDER AND JUDICIAL AND ADMINSTRATIVE PROCEEDINGS: We may disclose medical information in response to a court or administrative order, subpoena, discovery request, or other lawful process, under certain circumstances. Under limited circumstances, such as a court order, warrant, or grand jury subpoena, we may share the medical information or a suspect, fugitive, material witness, crime victim or missing person. We may share the medical information of an inmate or other person in lawful custody with a law enforcement official or correctional institution under certain circumstances.

 

PUBLIC HEALTH ACTIVITIES: As required by law, we may disclose your medical information to public health or legal authorities charged with preventing or controlling disease, injury or disability, including child abuse or neglect. We may also disclose your medical information to persons subject to jurisdiction of the Food and Drug Administration for purposes of reporting adverse events associated with product defects or problems, to enable product recalls, repairs or replacements, to track products, or to conduct activities required to the Food and Drug Administration. We may also, when we are authorized by law to do so, notify a person who may have been exposed to a communicable disease or otherwise, be at risk of contracting or spreading a disease or condition.

 

WORKERS COMPENSATION: We may disclose health information when authorized and necessary to comply with the laws relating to workers compensation or other similar programs.

 

LAW ENFORCEMENT: Under certain circumstances, we may disclose health information to law enforcement officials. These circumstances include the reporting required by certain laws, (such as the reporting of certain type of wounds), pursuant to certain subpoenas or court orders, reported limited information concerning identification and location at the request of a law enforcement official, reports regarding suspected victims of crimes at the request of a law enforcement official, reporting death, crimes on our premises, and crimes in emergencies.

YOUR INDIVIDUAL RIGHTS

You have the right to:

  1. Look at or obtain copies of your medical information. You may request that we provide copies in a format other than photocopies. We will use the format you request unless it is not practical for us to do so. You must make your request IN WRITING. You may request the necessary form by contacting this office or sending a letter.
  2. IF YOU REQUEST COPIES. WE WILL CHARGE YOU $3.50 FOR EACH PAGE, AND POSTAGE IF YOU WANT THE COPIES MAILED TO YOU. YOU MAY CONTACT US FOR A FULL FEE STRUCTURE.
  3. Receive a list of all the times we or our business associates shared your medical information for the purposes other than treatment, payment, and health care operations and other specified exceptions.
  4. Request that we place additional restrictions on our use of disclosure of your medical information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in case of an emergency).
  5. Request that we communicate with you about your medical information by different means or to different locations. Your request that we communicate your medical information to you by different means or at different locations must be made IN WRITING to our office
  6. Request that we change your medical information. We may deny your request if we did not create the information you want changed or for certain other reasons. If we deny your request, we will provide you with a written explanation. You may respond with a statement of disagreement that will be added to your information that you wanted to change. If we accept your request to change the information, we will make reasonable efforts to tell others, including people that you name, of the change and to include the changes in any future sharing of that information

QUESTIONS AND COMPLAINTS

For any questions relating to the Notice of Privacy Practices, please contact Hearing Life’s HIPAA Compliance Officer, Sara Francks, by calling 732-529-7120 or via standard mail to: Hearing Life, Inc., 387 Passaic Ave., Suite 113, Fairfield, NJ 07004.

I have read and agree to the above terms.