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.
Referring Physician Name*
Referring Physician Phone Number*
Patient First & Last Name*
Patient Phone*
Patient Date of Birth*
Patient Email*
NPI#*
Urgency
STAT
Urgent
Next Available
Reason for Visit*
For Medicare billing purposes, please either attach a doctor’s order for a hearing evaluation to this page or fax it to our office at (570) 489-4327.