New Patient Appointment Packet *Hearing Appointments*

Hearing Associates, Inc. Welcome! This packet will help you prepare for your visit!

1. Review, complete, and bring this packet, along with the other listed items, to your appointment

2. Check-in from your vehicle as our waiting room is closed

818-727-7020, ext. 7

What to expect during your visit…

Hearing Associates, Inc. is committed to delivering high-quality, essential care, while protecting the safety of our patients and team. We have adapted our protocols in support of social distancing to continue providing top-notch care to our patients. To help make appointments safer, easier, and more efficient, we request that you to complete this this packet and bring it to your appointment, along with all requested documents listed. This will help our team make your visit seamless and safe as possible. Our waiting room is currently closed, so we ask that you call to arrange for your safe entrance into the office. Thank you for being such an important part of our family!

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Schedule & confirm appointments 818-727-7020 Review and complete this packet prior to your visit Bring these items to your appointment:

Rev. July 2020

Questions?

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* Once invited to the door, please ring the doorbell, and take a step back. Our staff will take your temperature at the door & escort you directly into an exam room

Please do not leave exam room without a staff escort

Please do not hesitate to call if you are unsure about this process or have any questions contact us: 818-727-7020 or Christine@wchearing.com

Check-in by calling from your vehicle 818-727-7020 Masks must be worn at all times & COVID screenings are mandatory for all visitors

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-Completed packet -All Insurance Cards -Photo ID -Medication List -Up to 1 Companion/Guardian -Authorization/Prescription

18433 Roscoe Blvd.

Suite 204 Northridge, CA 91325

HEARING ASSOCIATES, INC.

COVID-19 Pandemic Appointment Consent Form Date:

Name of Patient:

Hearing Associates, Inc. 18433 Roscoe BoulevardSuite 204Northridge, CA, 91325

You have elected to receive care during the events of the COVID-19 National Emergency. We are providing this specialconsent because of the unique circumstances this pandemic. Some considerations to keep in mind as you seek testing and/or treatment under these unique circumstances:

• The ongoing community transmission of the COVID-19 virus creates additional risks from being in the proximity of

providers, patients, or staff that we want you to seriously consider before engaging in testing and/or treatment. Social distancing of 6 feet or more is NOT POSSIBLE during testing and/or treatments, which may increase the chances of COVID-19 transmission. It is estimated that aerosol droplets can linger in the air for minutes to hours and have the potential to transmit the COVID-19 virus.We are implimenting infection protocols which may limit the spread of the disease, but there is a still a possibility of transmission to you (and to others you come into contact with, after leaving this office) of the COVID-19 virus which can cause serious health problems, including but not limited to, severe respiratory problems, high fevers, and death.

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I fully understand and accept each statement:I understand that the COVID-19 virus has a long incubation period, during which carriers of the virus may not show symptoms but may still be highly contagious. It is impossible to determine who has it and who does not, given

the current limits in the virus testing.

I understand that due to the frequency of visits of other patients, the characteristics of the virus and

characteristics of procedures, that I have an elevated risk of contracting the virus by virtue of engaging in testing and/or treatments and by virtue of simply being in a medical office.

I understand that there is still much we do not know about the COVID-19 virus and, therefore, there may be risks that are yet unknown.

• Fever > 99.6• Shortness of breath or difficulty breathing• Dry Cough

• Chills• Muscle pain

• Headache• Sore throat• New loss of taste and/or smell

I confirm that I am NOT, now or in the past 14 days, presenting with any of the following symptoms of COVID-19:

I understand that travel by air, bus, or train significantly increases my risk of contracting and transmitting the COVID-19 virus. I verify that I have not traveled domestically within the United States by commercial airline, bus, or train within the past 14 days.I verify that I have not traveled outside of the United States in the past 14 days.I understand that the CDC currently recommends social distancing of at least 6 feet or more under many

circumstances and that social distancing of 6 feet or more is NOT POSSIBLE during testing and treatment.

The safety and well-being of our patients continues to be our primary concern. We will continue to monitor the status of COVID-19 nationally and within our community and update office policy as needed to continue to provide services to our community. I have read this entire document, and I knowingly and willingly consent to have testing and/or treatment during the COVID-19 pandemic, despite the risks discussed in this consent.

Signature of Patient or Signature of Patient’s Parent / Legal Guardian

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Name of Patient (print) or Name of Patient’s Parent/ Legal Guardian (print)

Date of Signing rev. 20/07/01

PatientPersonalInformation:

Name:__________________________________________________________________________ (LastName,FirstName,MiddleInitial)SocialSecurity#:_______________________Driver’sLicense#:___________________________Gender:M___F___Other___Age:_______DateofBirth:___________________________PrimaryLanguage:________________________________________________________________HomeAddress:___________________________________________________________________

City:____________________________________________State:_________Zip:_____________HomePhone:____________________________CellPhone:_______________________________E-mailAddress:________________________________________________________________________Initialifwemaycontactyoubye-mailEmployer:___________________________________Occupation:_________________________MaritalStatus:Married___Single___Divorced___Widowed___Other:____________________Ifchildisunder18yrsofage,Parent/Guardian(s)Name:__________________________________EmergencyContactName:____________________________________Phone:________________Relationship:_____________________________________________________________________PrimaryPhysicianName:_____________________________________Phone:________________Address:________________________________________________________________________ReferringDr.Name(IfdifferentfromPrimary):________________________Phone:________________Address:________________________________________________________________________ReferralSource: ___ReturningPatient ___Insurance ___MedicalGroup Physician:______________

___Newspaper ___Mailer ___OfficeReminder Patient:________________ ___Website Internet/SocialMedia:________________Other:_________________

Insurance:PrimaryInsuranceCompany:_______________________________________________________________Policy/Member#:_____________________________Group#:___________________________________MedicalGroupName:__________________________SocialSecurity#:____________________________Insurer’sName:__________________________________________________________________________

SecondaryInsuranceCompany:_____________________________________________________________Policy/Member#:_____________________________Group#:___________________________________MedicalGroupName:__________________________SocialSecurity#:____________________________Insurer’sName:__________________________________________________________________________

IherebyauthorizeanddirectmyinsurancecompanytomakepaymentstoHEARINGASSOCIATES,INC.,benefitsallowableandotherwisepayabletomeand/ormydependents.IunderstandthatIamresponsibleforchargesnotpaidunderthisAssignment.Thisauthorizationwillremainineffectuntilrescindedmyselfinwriting.AphotocopyofthisAssignmentmaybehonored.PatientSignature:____________________________________ Today’s Date: _____________________________ Ifpatientisunder18yrsold,Guardian/Parenttosign:___________________________________________________

HEARING ASSOCIATES, INC 18433 Roscoe Boulevard, Suite 204

Northridge, California 91325 Tel. 818-727-7020 * Fax. 818-727-7075

www.HearingAssocaiatesNorthridge.com

PATIENTLASTNAME:_________________________________FIRSTNAME:________________________________________

DATEOFBIRTH:________________________________CHART#________________ DATE:____________________Provider:___AngelicaO'Boyle,AuD,CCC-A___CarolinaHernandez,HAD,AA&___Other:

OFFICEUSEONLY

Howmuchdifficultydoyouhavehearing?(None)010(Significant)Doyoucurrentlywearhearingaid(s)? YES NO

Doyouhavenoises,likeringing,inyourear(s)? YES NO

>>Ifyes,howbothersomearethesounds?(Not)010(Extremely)

PLEASEANSWERYESORNOTOTHEFOLLOWINGQUESTIONS: YES NO

Haveyoueverhadanyhead,orear,injuriesorsurgeries?

Doyouhaveearpain?

Doyouhavedrainagefromyourear(s)?

Doyoufeelpressureorapluggedfeelinginyourear(s)?

Haveyoueverhaddizziness,vertigoorbalanceproblems?

Haveyoueverhadexposuretoloudnoises?(music,machines,tools,guns)

Doyoumisssomewordsandhavetoaskpeopletorepeat?

Doesitsoundlikepeoplefrequentlymumble?

DoyouraisetheTVvolumeand/orhavedifficultyunderstanding?

Doyouhavedifficultyhearingoverthetelephone?

Doyouhavetostraintounderstandconversationsingroups?

Doyouhavetroubleunderstandinginthepresenceofnoise?

Doyouhavetroubleunderstandinginmeetings,church,orlectures?

Dopeoplebecomeannoyedbecauseyoudon'tunderstand?

Havefamilymembersaskedyoutohaveyourhearingchecked?

Doyouhavefamilymemberswithhearingloss?

Doyouavoidsocialactivitiesduetoyourinabilitytohear?

Forthepastmonth,haveyouoftenlackedinterestorpleasure?

Forthepastmonth,haveyouoftenfeltdepressedorhopeless?

Doyoufeelyouareavictimofphysical,mentalorfinancialabuse?

Doyousmokeorusetobacco/tobacco-likeproducts?

Doyouhaveanyvisionordexterityproblems?

SUMMARYDETAILS:CONCLUSIONS/IMPRESSION:SNHLCHLMIXEDHLADASAUSNHLCHLMIXEDHLADASRECOMMENDATIONS:___Medical&/orENTfollowup____HearingAidEvaluation____ABR____VNGOTHERRX:

Whatbroughtyouintoday?

ForOfficeUseOnly

HEARING ASSOCIATES, INCADULTEVALUATION&MANAGEMENTRELEVANTHISTORY

Hearing Associates, Inc. 18433 Roscoe Boulevard, Suite 204 Northridge, California 91325 Tel. 818-727-7020 * Fax. 818-727-7075 www.HearingAssociatesNorthridge.com

If you are unsure of your medication name, please list what you take medication for.

***IF YOU HAVE A PRE-MADE LIST, PLEASE GIVE DIRECTLY TO STAFF ***

INITIALS DATE

I HEREBY ACKNOWLEDGE THAT A COPY OF

HEARING ASSOCIATES NOTICE OF

PRIVACY PRACTICES & MARKETING RELEASE WAS MADE AVAILABLE TO ME

__________________________________

Reason/Illness

PATIENT MEDICATION LIST

Name of Medication Dosage

*If you do not take any prescribed medications, please write "none"

How Often Taken

Today's Date:

Patient's Name:

HEARING ASSOCIATES, INC 18433 Roscoe Boulevard, Suite 204

Northridge, California 91325 Tel. 818-727-7020 * Fax. 818-727-7075

NoticeofFinancialandPaymentPolicy

Welcome!ItisourpleasuretoservetheOjaicitycommunity.Pleasereadthefollowingofficepolicies.Ifyouhaveanyquestionspleaseaskastaffmemberforanswerstoyourneeds.

• Insurance(ParticipatingProviders)WeparticipatewithmanyInsuranceCompaniesincludingMedicare.WearealsoacontractedProvider’swithHMOMedicalGroups.IfyouareunsureifwearecontractedwithyourInsuranceCompanypleaseasktheFrontOfficebeforebeingseenbytheAudiologist.IfwearenotacontractedProviderwithyourInsuranceCompany,youmaybebilledifaCo-InsuranceorDeductiblewasappliedtoyourpolicy.

• Payment/Co-PaymentsPaymentforanyHearingAid(s)servicesaredueatthetimeofservicesunlessotherarrangementsaremade.Ifyouareoutofour“OfficeWarranty”,oryoudidnotpurchaseyourHearingAid(s)inouroffice,youmayberesponsibletopayforservicesonyourHearingAid(s).

• Returned/Stopped/BouncedChecksYouwillbechargeda$35.00fee,inadditiontoyourbalancedue.

• Penalties&OfficeBillingFeesOnceyourInsurancecompanieshavesettledyourclaim,youmayreceiveabillforanybalance,whichisconsidered“PatientResponsibility”.Thismayincludedeductibles,co-payments,co-insurancesnotpaidatthetimeofservice.Pleasepayyourbillpromptly.Ifnotpaidwithin90daysitwillbeforwardedtoaCollectionCompany.Ifyouneedtomakeanypaymentarrangementspleasedoitwiththebillingservices.

• MissedAppointment&SameDayCancellationFeeOurofficewillchargeafeeof$25.00-$100.00foranypatientthatdoesnotcall24-48hrspriortotheirappointmenttocancel,reschedule,ortheymisstheirappointment.Thefeewillbebasedonthetypeofappointmentthatwasscheduled.Inordertorescheduletheappointment,wewillaskforacreditcardnumbertotemporarilykeeponfile.Therewillonlybeafeechargedifthepatientdoesnotcall24-48hrspriortotheirappointmenttocancel,reschedule,ortheymisstheirrescheduledappointment.

If you have medical insurance, we are pleased to help you receive your maximumallowancebenefits. Inordertoachievethesegoals,weneedyourassistanceandyourunderstanding of our payment policy. Youwill be asked to update your demographicandinsuranceinformationperiodically,includingprovidingourofficewithcopiesofALLyour insurance card(s). We are required to obtain your signature for permission toreleaseinformationtoyouinsurancecarrierannually.

________________________________________________ _________PrintPatientName/Guardian Patientsignature/Guardian Date