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Patient Registration Form

Name(Required)
Address(Required)
Primary Number
Date of Birth
Sex

Marital Status

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Primary Insurance Information

If patient is the insured, enter ‘SAME’ for name and address

Name
Address
Patient Relation to Insured

Insured's Date of Birth
Insured's Sex

Other Insurance Information

If patient is also the insured, enter ‘SAME’ for name and address

Name
Address
Patient Relation to Insured

MM slash DD slash YYYY
Insured's Sex

I authorize any holder of medical or other information about me to release any information needed to process this or other claims. I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits either to myself or to the party who accepts assignment.

Syracuse Hearing Solutions – PATIENT HIPAA CONSENT FORM

Last revised December 06, 2019

I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent, I authorize you to use and disclose my protected health information to carry out:

  1. Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment)
  2. Obtaining payment from third-party payers (e.g. my insurance company); The day-to-day healthcare operations of your practice

I have also been informed of and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information, and my rights under HIPAA. I understand that Syracuse Hearing Solutions reserves the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice.

I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment, and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction.

My “protected health information” (“PHI”) means health information, including my demographic information, collected from me and created or received by my physician, another health care provider, a health plan, my employer or a health care clearinghouse. This protected health information relates to my past, present or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me.

I consent to Provider’s use or disclosure of my PHI for purposes of delivering relevant product and/or technology marketing communication to me. I acknowledge that Provider may receive financial remuneration from the manufacturer in connection with such communications.

MM slash DD slash YYYY
Patient's Name

PERMISSION TO RELEASE RECORDS:

We provide you with important diagnostic information about your hearing. We feel it is important for your physician to have this information for your medical records. By signing this form you are providing us permission to send a copy to your physician(s), and/or any relevant parties that are listed below. This release will be in effect until we receive a written notice from you requesting we may no longer forward this information.

This waiver authorizes Syracuse Hearing Solutions to send/give my medical information as noted (Check all that apply):

PERMISSION TO OBTAIN RECORDS:

In order to provide you with the best service possible, we may be required to contact your physician, previous audiologist, hearing aid dispenser, or hearing aid manufacturer for information regarding your hearing, hearing aid information, warranty, etc. This release will be in effect until we receive a written notice from you requesting we no longer forward this information.

Date