This form complies with the Federal Health Insurance Portability and Accountability Act (HIPAA). This is a secure form; the information that you enter here will be seen only by the staff of our practice.

Directions: fill out all applicable fields and submit the form. We will contact you if there are any concerns or errors with your submission.
 
 

Primary Phone Type:

    

Alternate Phone Type:

    
Please check employment status:


 

Hear Virginia supports the ‘No Surprises Act’ that is designed to protect uninsured/self-pay/out of network patients from unexpected medical bills. Your request must be received three business days prior to your visit.

 

Insurance Information
If applicable, please present your insurance information to our front office staff.

 

Please Read Carefully and Sign Below

  • I agree to allow Hear Virginia to release information contained in my record to my healthcare providers as it relates to my hearing healthcare needs.
  • I give permission to Hear Virginia to release information contained in my record to my insurance company, if applicable. 
  • I understand and agree that, regardless of my insurance status, I am ultimately responsible for the costs of professional services rendered by, and products sold by, Hear Virginia. 
  • I acknowledge that I have received and reviewed the Health Insurance Portability & Accountability (HIPAA) policy of this office. (Copies are available at our front desk.) 
  • I certify that this information is true and correct to the best of my knowledge, and I hereby give Hear Virginia permission to treat my hearing healthcare needs.