First Name:

Last Name:

Age:

Date of Birth:

Demographics

Address*

City*

State*

Zip*

Home Phone

Work Phone

Cell Phone

Email*

Gender*

Male Female Other

Social Security number

Driver's License

Emergency Contact Information

Emergency contact name*

Relationship to patient*

Phone*

Address*

City*

State*

Zip*

Referral Source

Insurance Information

Insurance Name

Subscriber's Name

Subscriber's Date of Birth

Subscriber's SSN

Subscriber's Relationship to Patient

Employer Name

Employer Phone

Subscriber's policy number

Group number

Insurance claim mailing address

Do you have secondary insurance?

Yes No

Occupation:

Reason for visit:

Referring Physician:

Referring Physician Phone #:

Referring Physician Address:

Primary Care Physician:

Primary Care Physician Phone #:

Primary Care Physician Address:

Family Doctor/Internist:

Family Doctor/Internist Phone #:

Other Doctor Involved in Your Care:

Other Doctor Involved in Your Care Phone #:

Drug allergies:
Pharmacy Name:
Pharmacy Address:
Pharmacy Phone Number:
Current Medications

Ears:

Hearing loss

Right Left Both N/A

Ear pain

Right Left Both N/A

Ear drainage

Right Left Both N/A

Ringing/noise

Right Left Both N/A

Hearing aid

Right Left Both N/A

Who is your hearing aid dispenser?

Noise Exposure:

Occupational

Neurological

Previous Ear Surgeries: N/A

Family History of Hearing Loss: N/A

Past Medical History:

Other Surgeries:

Family Medical History:

Social History

Do you live alone?

Yes

Who lives with you?

How much caffeine do you drink per day?

Coffee

Tea

Soda pop

Chocolate

Do you smoke marijuana?

Yes

How much?

Do you drink alcohol?

Yes

Quantity?

Do you take any street drugs?

Yes

Please explain:

Are you at risk for AIDS (e.g. sexual orientation, drug abuse, previous blood transfusion)?

Yes

Please explain:

Eyes

Wear glasses

Yes No

Visual changes

Yes No

Glaucoma

Yes No

Cataracts

Yes No

Endocrine

Diabetes

Yes No

Thyroid Disease

Yes No

Hormone Problems

Yes No

Fever

Yes No

Weight Loss/Gain

Yes No

Excessive Fatigue

Yes No

Cardiovascular

Chest Pain or Angina

Yes No

High Blood Pressure

Yes No

Irregular Pulse

Yes No

Heart Murmur

Yes No

High Cholesterol

Yes No

Swelling in Feet or Hands

Yes No

Leg Pain while Walking

Yes No

Gastrointestinal

Indigestion

Yes No

Nausea

Yes No

Vomiting

Yes No

Liver Disease/Hepatitis

Yes No

Abdominal Pain

Yes No

Change in Bowel Habits

Yes No

Ulcers or Gastritis

Yes No

Nose

Nasal Congestion

Yes No

Nasal Drainage

Yes No

Sinus Problems

Yes No

Environmental Allergies

Yes No

Psychiatric

Anxiety

Yes No

Depression

Yes No

Insomnia

Yes No

Suicidal Thoughts

Yes No

Respiratory

Asthma

Yes No

Bronchitis

Yes No

Chronic Cough

Yes No

Emphysema

Yes No

Shortness of Breath

Yes No

Pneumonia

Yes No

Tuberculosis

Yes No

Genitourinary

Urinary Tract Infections

Yes No

Painful Urination

Yes No

Blood in your Urine

Yes No

Incontinence

Yes No

Difficulty Voiding

Yes No

The above information is accurate to the best of my knowledge.

Patient's Signature:

DATE:

Ear Associates & Rehabilitation Services

Summary Notice of Privacy Practices

This is a summary of our Notice of Privacy Practices, which describes how we may use and disclose your medical and personal information and how you can have access to this information. We have attached a full version of the notice.

Our Pledge to Protect Your Privacy

The office of Ear Associates and Rehabilitation Services, Inc. is committed to protecting the privacy of your medical and personal information. So that we may best meet your medical needs, we share your medical records with the health care providers involved in your care period we share your information only to the extent necessary to collect payment for the services we provide, to conduct our business operations and to comply with the laws that govern healthcare. We will not use or disclosure information for any other purpose without your permission.

Your rights regarding medical information about you:

To inspect and obtain a copy of your medical records with certain limitations
To request an amendment or addendum to your medical record
To an accounting of EARS, Inc. disclosures of your medical information
To request restrictions on certain uses and disclosures of your medical information
To request when and where to contact you
To request a copy of the full version of our Notice of Privacy Practices
We may use in disclosure personal and health information without your authorization for the following purposes:
To provide you with medical treatment
To bill and receive payment for the treatment received
As required and permitted by law for functions necessary to run the office of EARS, Inc., and assure that our patients receive quality care for public health activities (e.g., reporting abuse)
For research purposes in limited circumstances
To a coroner, medical examiner, funeral director, or organ procurement organization for certain purposes
To a court or administrative order, subpoena, discovery request or other lawful process
To a health oversight agency, such as the California Department of Health Services
We reserve the right to change our privacy practices and update this notice accordingly. Please see our full Notice of Privacy Practices for a more detailed description of our privacy practices. For further information or questions, please contact the privacy officer at (408) 540-5400.

PLEASE SELECT (REQUIRED):
YES, I give permission to leave a confidential voicemail.
NO, I do not give permission to leave a confidential voicemail.

YES, I give permission to speak to another designated individual about my care.
NO, I do not give permission to speak to another designated individual about my care.

Name of designated individual(s):

Relationship(s):

Signature of patient or Legal Representative:

If Legal Representative, indicate relationship to patient:

I have read and understand my rights:

Signature of Patient of Legal Representative

DATE:

FINANCIAL AND OFFICE POLICIES

Cancellation/ Missed Appointment Policy
Our office will notify you by TeleVox three days prior to your appointment. It is your responsibility to ensure we have an up-to-date telephone number on file.

As our audiology and medical schedules are intertwined, a 48-hour advance notice for cancellation or rescheduling of all appointments is required. We Reserve the right to reschedule your appointment if you arrive more than five minutes late to your scheduled appointment/ test. Patients who cancel without notice or miss more than three appointments will be charged a fee of $300. This fee is not covered by Medicare or insurance planes.
Co-Payments
Our office requires co-payments be paid on the day of your appointment. There will be a $25 fee for any co-payment that is not paid at this time.
Refunded Checks
Our office charges a $30 fee for all returned checks.
Electronic Services Policy
Dr. Maw is pleased to offer patients professional services by electronic means and completion of insurance , work or other forms. These services are subject to a minimum of $25.00 charge and are otherwise prorated for 90 days post surgery, but otherwise are the responsibility of the patient.
Assignment, Release and Financial Agreement
I authorize treatment of {{Patients Name}}
and agree to pay all fees for services and treatment provided by Dr. Jennifer Maw and/or her designated providers. I hereby authorize my insurance benefits to be paid directly to Dr. Maw for services provided, and I realize that I am financially responsible for any services not covered by my insurance company, I agree that I will not withhold or delay payment if my insurance company denies payment on any charges. I Understand that my insurance company may deny payment for any reason including but not limited to services not authorized by my primary care provider and services not authorized/covered by my insurance company. Any claims paid to Dr. Maw by the insurance provider after full payment by the patient will be refunded . I acknowledge that failure to meet my financial obligations may result in referral of my account to a collection agency.

I have read and understand all of the above financial and office policies.

Father	Alive Deceased	Age	Health status or cause of death
Mother	Alive Deceased	Age	Health status or cause of death
Brother/Sister	Alive Deceased	Age	Health status or cause of death
Brother/Sister	Alive Deceased	Age	Health status or cause of death
Brother/Sister	Alive Deceased	Age	Health status or cause of death

Demographics

Emergency Contact Information

Referral Source

Insurance Information

Secondary Insurance

Ears:

Noise Exposure:

Neurological

Social History

Eyes

Endocrine

Cardiovascular

Gastrointestinal

Nose

Psychiatric

Respiratory

Genitourinary

The above information is accurate to the best of my knowledge.