Patient Intake Form

FINANCIAL AGREEMENT: I hereby authorize payment directly to Arch Audiology, LLC for any diagnostic testing, in office procedures, and hearing aid services, purchases, supplies, etc. I understand that I am financially responsible for any bills. I understand that a $50 no-show fee will be added to my account for each occurrence after the second occurrence. I understand there will be a $25 returned check fee added to my account for each occurrence. I understand and agree that a 35% collection fee will be added to any balance on this account should it be placed with a collection agency.

PRIVACY POLICY: I consent to the use or disclosure of my protected health information by Arch Audiology, LLC for the purpose of diagnosing or providing treatment to me, obtaining payment for my health care bills, or to conduct health care operations of Arch Audiology, LLC. I understand that diagnosis or treatment of me by Kristen Kramer may be conditioned upon my consent as evidenced by my signature on this form. I understand that copies of my test results may be released to my primary care physician or other health care provider for their records, and may be released to a hearing aid manufacturer to assist the manufacturer in making an appropriate hearing aid for your particular hearing loss. I understand that my protected health information may be shared with a third party administrator or health insurance company to obtain benefit information. I understand that my protected health information may be shared with family members (i.e. spouse, children) and/or residential facilities (i.e. nursing homes, retirement communities, etc.) who may call the office of Arch Audiology, LLC on my behalf. I understand I may be contacted by email or text message for appointments, for questions, or when I have been unreachable by telephone.