To submit this form, please ensure all required fields are filled out accurately. You can then send the completed form via email to our designated address or submit it through our online portal. For any physical submissions, please send the form to the specified mailing address provided in the contact section.

For the upcoming years, ensure all forms related to patient care are updated before the beginning of each fiscal year. Regular updates will be required to comply with healthcare regulations. Key dates for patient follow-ups should be meticulously noted.

The purpose of this form is to streamline the process of collecting patient information for those utilizing Hearing At Home services. It aims to facilitate better communication and service delivery in the mobile healthcare model. This form also assists in maintaining essential records that comply with state laws.

• 1. Patient Name: Full name of the patient requiring hearing services.
• 2. Contact Information: Phone number and address for patient correspondence.
• 3. Medical History: Brief overview of the patient's medical background related to hearing.
• 4. Consent Signature: Field where the patient can provide their electronic signature for consent.

Failure to submit this form may result in delays in receiving necessary hearing services. It's crucial to ensure that all fields are completed accurately to avoid complications in scheduling appointments. Incomplete submissions can hinder the provision of timely care.

• Delayed Service: Incomplete forms may cause a backlog in scheduling services.
• Lost Patient Information: Failure to submit may lead to missing critical patient details.
• Financial Implications: Inaccurate submissions can affect pricing and billing accuracy.

• 1. New Patient Onboarding: Essential for gathering initial patient information.
• 2. Service Updates: Used to refresh records as patients' situations evolve.
• 3. Insurance Documentation: Required for submitting patient data to insurance providers.