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

Physician

Audiologist

Friend or Family Member

Internet/Website

Insurance Company or Hospital

Marketing

Other

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

Secondary Insurance

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

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:

Neurological

Spinning

Yes No

Swimming sensation

Yes No

Loss of balance

Yes No

Veering to side

Yes No

Falls

Yes No

Lightheaded/giddy

Yes No

Fainting/blackouts

Yes No

Headaches

Yes No

Migraine history

Yes No

Previous head injury

Yes No

Difficulty with speech/swallowing

Yes No

Numbness/weakness of arms/legs

Yes No

Facial weakness

Yes No

Neck problems

Yes No

Jaw problems

Yes No

Previous Ear Surgeries:

Family History of Hearing Loss:

Past Medical History:

Family Medical History:

Social History

Marital Status Married Single Divorced Widowed

Do you have children?

Yes

How many?

Do you live alone?

Yes

Who lives with you?

How much caffeine do you drink per day?

Coffee

Tea

Soda pop

Chocolate

How much salt do you eat?

Low salt diet

No added salt

Regular intake

Do you smoke?

Yes

Packs/day

E-cigarettes/day

Cigars/day

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:

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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.

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.

We may use in disclosure personal and health information without your authorization for the following purposes:

We reserve the right to change our privacy practices and update this notice accordingly. 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):

I have read and understand my rights.

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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 plans.

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.

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 $25.00 charge and are otherwise prorated at an hourly charge of $400.00/hour. Dictated letters are $100.00 per page. These charges do not apply to the postoperative patients for 90 days post surgery, but otherwise are the responsibility of the patient.

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.

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.