All hearing aids are different. It may be confusing to receive so many ads about many different hearing aids from many different hearing aid companies. There are so many different opinions on hearing aids that it makes it difficult to know what would be right for you. Are you concerned about investing in a hearing aid that may work for someone else, but may not work for you? Your hearing needs may be very different from someone else’s needs and we take that into consideration when helping you choose a hearing aid.

We carry most major manufacturers brands of hearing aids and have experience fitting over hundreds of different models of hearing aids.

Our Doctors of Audiology have the expertise to help you find the right hearing aid for you based on your hearing test results and your answers to the following questions…

Please attach your hearing test results and fill out the questionnaire so we can determine which hearing aid may be best for you.

Do you feel that you can hear but you can’t understand?

All the time Most of the time Some of the time None of the time

Do you feel that you rely on reading lips or seeing the speaker’s face in order to hear?

All the time Most of the time Some of the time None of the time

Are you sensitive to certain sounds?

Yes No Sometimes

Do certain sounds bother you?

Yes No Sometimes

Do certain voices bother you?

Yes No Sometimes

Which voices are most difficult to understand?

Male Female Child All of the above None of the above

Do you feel that you need to hear better..

All the time Most of the time Some of the time None of the time

Do family members and friends complain you can’t hear them?

All the time Most of the time Some of the time None of the time

Are you outdoors a lot?

Yes No Sometimes

Are you in loud surroundings?

All the time Most of the time Some of the time None of the time

Can you handle small batteries?

Yes No Sometimes

How would you consider your manual dexterity?

Excellent Good Fair Poor Unsure

Have you been told you have small ear canals in the past?

Yes No Unsure

Are you prone to sweating?

Yes No Sometimes

Do you feel you would have trouble putting a hearing aid on…

in your ear behind your ear both no trouble at all

Have you been told that you produce a lot of earwax?

Yes No Unsure

Do you consider yourself tech-savy?

Yes No Maybe Unsure

Do you have a smartphone?

Yes No Don't know what that is

Do you know about Bluetooth?

Yes No Somewhat Unsure

Would you be afraid of losing your hearing aids and want a way to track them with your phone?

Yes No Unsure

Would you like the ability to hear television, music, sound, directed wirelessly through your hearing aids?

Yes No Maybe Unsure

Do you feel that your lifestyle is..

Very active and attend varying social situations

Somewhat socially active, going out to social occasions sometimes

Mostly quiet lifestyle

Indoors and in quiet all of the time

What level of hearing aid technology are you most likely to consider?

I want the best of the best technology for me

I don’t feel I need the best, but I don’t want to be unhappy if I go for less

I would like to hear better, but I am on a strict budget

If you answered yes to one or more of the previous questions, you should have a complete hearing evaluation performed by our audiologist

Finish the form below and a specialist will be in touch to set up your appointment.

First Name

Last Name

Email Address

Phone Number

Do you experience a feeling of motion, spinning or falling when moving your head quickly or changing your position? (ex. getting in and out of bed)

Yes No

Do you feel uncomfortable when trying to get around in the dark?

Yes No

Is walking down the grocery store aisles or through the mall upsetting?

Yes No

Do you feel that your feet just won't go where you want them to?

Yes No

Do you feel a sense of unsteadiness? A feeling you are not sure-footed?

Yes No

Do you experience a fear of falling or stumbling?

Yes No

Do you feel queasy when looking at moving objects such as escalators or when looking out the side window of a car?

Yes No

Do experience feelings that no one really understands how frustrating this is?

Yes No

If you answered yes to one or more of these questions, a vestibular and equilibrium evaluation should be considered. To schedule an appointment fill out the fields below!

First Name

Last Name

Patient Registration Form

Syracuse Hearing Solutions

5639 W Genesee St. Camillus, NY 13031

Phone: 315-468-2985 Fax: 315-320-0245 Email: info@syracusehearing.com

Patient Information

First Name

Initial

Last Name

Responsible Party

If patient is a child, Parent or Guardian

Address

City

State

Zip Code

Home Phone

Work

Mobile

Other

Primary Number

H W M O

Date of Birth

Sex

M F O

Marital Status

Choose one

Employment Status

Choose one

Student Status

Choose one

Referring Physician

Primary Physician

Is there a place/physician we can send a copy of your test results?

Emergency Contact

How did you hear about us?

How would you like to receive appointment notifications?

Telephone Text Email None

Primary Insurance Information

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

Office Only

Insurance Card Copy on file?

First Name

Initial

Last Name

City

State

Zip Code

Home Phone

Work Phone

Patient Relation to Insured

Insured's Date of Birth

Insured's Sex

M F O

Insured's Employment Status

Insured's Employer

Insured's Co. Name

Subscriber ID #

Group #

Other Insurance Information

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

Office Only

Insurance Card Copy on file?

First Name

Initial

Last Name

City

State

Zip Code

Home Phone

Work Phone

Patient Relation to Insured

Insured's Date of Birth

Insured's Sex

M F O

Insured's Employment Status

Insured's Employer

Insurance Co. Name

Subscriber ID #

Group #

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.

Signed

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:

Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment)
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.

Signature of Patient or Personal Representative

Name of Patient or Personal Representative

Date

Description of Personal Representative's Authority

Patient 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.

I authorize release of my records to the following:

Physician or Referring Agency

This waiver authorizes Syracuse Hearing Solutions to send/give my medical information as noted:

Leave a voice mail recording including my Personal Health information on my home/cell phone

Leave a voice mail recording including my Personal Health information on my business phone

Permit Syracuse Hearing Solutions to share personal health information with other health care providers, family members and/or school personnel as necessary to carry out my care

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.

I authorize permission to obtain my records from. the following:

PATIENT SIGNATURE or GUARDIAN SIGNATURE

DATE

PRINT PATIENT NAME

RELATIONSHIP TO PATIENT