Advanced Audiology Associates | New Patient Info Form

Patient Information Form, HIPAA and Insurance Payment Consent

I authorize Advanced Audiology Associates, Inc. to release information requested with regard to processing my claims. I understand and agree that (regardless of my insurance status), I am ultimately responsible for the balance on my account for any professional services rendered. I have read all the information on this sheet, and certify that this information is correct to the best of my knowledge

I accept full responsibility for all charges in the event that I have no insurance or third party benefits. Charges 30 days past due are subject to late fees.

I consent to receive non-marketing text messages from Advanced Audiology Associates, Inc. about appointment reminders, confirmations, hearing test results, and patient care updates. Message frequency may vary. Message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

I consent to receive marketing text messages about special offers, discounts, and service updates from Advanced Audiology Associates, Inc. at the phone number provided. Message frequency may vary. Message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

By submitting this form, you acknowledge our Privacy Policy and Terms & Conditions. SMS consent is optional and not required to submit this form.