Appointment Must-Haves

Please fill out your new patient forms by going into our Patient Forms
If you are scheduled to see one of our Audiologists for a hearing evaluation, please download and fill out the hearing history form by clicking here.

Preparing for your Visit

To Our Valued Patients

We strive to keep our forms as simple as possible, while at the same time capturing vital information that is necessary for your visit with us.

Privacy and Identity theft issues in our culture today are always a concern and we understand your apprehension to share key information.  

We want you to know that we take great measures to protect your information.  We hold ourselves responsible to know and abide by all confidentiality legislation.  These include:

  • HIPAA
  • FACTA
  • GLB Safeguard rule

Let us explain why we need certain information that you may pause to share.

  • A copy of your driver’s license is necessary to picture ID you.
  • Your social security number.  Most insurance companies have now removed this from your insurance card, so why would we still need this?
    • To verify your true identity if someone else tries to use this same information.
    • We also speak with your insurance company on your behalf and if there is a conflict of information, they most always will verify with a social security number.

  • Your employment information.
    • To verify benefits.
    • To reach you in an emergency.
    • To schedule surgery or procedures (we will not share with your employer why we are calling).

  • We ask, “Who can we share your medical information with?”  We protect your privacy, especially with family members who do not reside with you.

  • Please realize that in a divorce or separation situation where children are involved, Ohio State Law states that both parents are entitled to know the state of their child’s health.

  • Race, Ethnicity, Primary Language and Religion are now fields on your registration form. These are mandatory fields that the government now requires.