New Patient Information Packet

Audiology is the assessment and treatment of hearing disorders. Audiologists are hearing healthcare professionals who identify, assess, and manage disorders of the auditory system. They select, fit, and dispense amplification devices such as hearing aids and assistive listening technology to help you hear clearer and better. Essentially, your audiologist provides rehabilitation to improve the quality of your hearing.
Your initial evaluation will be a hearing screening to determine if any hearing loss is present. It takes about an hour. During this time, your audiologist will take a thorough history of your situation. If necessary, she will perform a hearing test while you sit comfortably in a sound booth to listen for various tones and words. She will also take a look inside your ear canal to look for obstructions or other factors, which may cause a hearing loss. After the evaluation and if it is determined that a hearing aid is necessary, your audiologist may recommend a medical referral to a doctor or work with you on selecting the most appropriate hearing system.
At PHC, you will find a wide selection of hearing instruments from the most advanced fully digital hearing aids to basic analog hearing aids. Your audiologist’s main objective is to find the most comfortable, affordable, and appropriate hearing device for your individual needs and lifestyle.

We look forward to seeing you!

 

Peninsula Hearing Center, Inc.
Patient Registration Form

    PART A

    Gender
    MF
    Cell
    How do you prefer to be contacted? HomeCellWorkEmail
    Relationship
    Is this person authorized to receive your medical information?
    YN
    Would you like us to verify your hearing aid benefits with your current health insurance?
    Please provide your insurance card to the front office to verify your benefits.

    Patient Privacy Notice

    This notice describes how your healthcare information obtained in this practice will be used for the purpose of diagnosing and treating hearing and balance disorders as required by the Privacy Regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Please review it carefully.

    • Your personal information will be disclosed only for the purpose of treatment, insurance billing and healthcare operations (such as ordering a hearing instrument). Disclosures of your personal health information for any use other than the above mentioned purposes will require your written authorization; except as required by law, (i.e. judicial proceedings, law enforcement, public health emergencies).
    • Authorized disclosures by you of your healthcare information for uses other than payment, treatment, and healthcare operations will be maintained in your electronic chart. You may request to see a list of these disclosures.
    • Our office routinely makes reminder telephone calls to confirm appointments. If we reach an answering machine, we will leave a message with our practice name and the time and date of your appointment. If you do NOT want us to leave you a message, please contact the front desk.
    • Any information you send to us (pictures, stories, letters, biographies, thank-you notes, etc.) becomes the exclusive property of Peninsula Hearing Center, Inc. We reserve the right to use non-identifying information about our clients for fundraising and promotional purposes that are directly related to our mission. Clients will not be compensated for use of this information. As a valued client, you will be receiving offers from our office by email, mail, or by phone regarding services that may personally benefit you. We may or may not receive financial compensation from third party sources for marketing purposes. Clients may specifically request, in writing, that no information be used for promotional purposes; however, we are not responsible for purchased mailing lists to random databases. We reserve the right to release information regarding your treatment to your physician and/or referring agency. We also retain the right to call you for your follow-up services.
    • You have the right to restrict our use and disclosure of your personal information. You may request to make changes and amendments at any time.

    If you have any questions or concerns regarding our privacy practices please contact us.

    Your signature below indicates you have been given an opportunity to read PHC’s Notice of Privacy Practices.

    I do not currently have an email address.


    Patient Financial Policy for Peninsula Hearing Center, Inc.

    Patient Name
    DOB

    As a hearing health care provider, we give our first time patients a free hearing consultation. After the first initial appointment, as a patient, you agree to pay for all portion of services in full, at the time services are provided by our office.

    Patient Financial Policies:

    You are required to present a valid insurance card at every visit and prior to the purchase of hearing aids. Unfortunately we are unable to back bill for services or products. A social security number may be required for some insurance companies.

    If you have no showed for more than three appointments, we will dismiss you as a patient, as this time could have been given to another patient. Please give 24-hour notice when cancelling appointments.

    Commercial Insurance Carriers:

    We work with most major insurances and will bill these carriers for you if proper paperwork and insurance cards are provided to us prior to services. If you do not provide us with insurance information prior to services rendered you are responsible for all fees payable to us and responsible for billing your own insurance should you choose to do so. Verification of coverage is not a guarantee of benefits and there may be fees in addition to your co pay. Any outstanding balances, co-payments and deductibles are due at the time of your appointment.

    Hearing aid benefits quoted by an insurance company are not a guarantee of payment. On occasion, insurance companies make errors in processing claims and your EOB may show a different amount owed than originally quoted. You are responsible for any balance not paid by your insurance company.

    Worker’s Compensation:

    If your visit is work related, we will need the case number and carrier name prior to your visit in order to bill the worker’s compensation insurance company.

    Methods of Payment:

    Our office accepts the following payment methods: Cash, Personal Check, and Credit Cards.

    For returned checks, we assess $25 NSF charge. If not paid according to these terms, the patient understands that our office reports to an outside collection agency. In the event that your account is turned over for collections, you are responsible for all additional fees assessed in the collection of the debt. These fees include collection agency fees and attorney fees and you will be dismissed as a patient. The patient is ultimately responsible for all fees for services.

    I do not currently have an email address.
    Date
    Signature

    Office Directions and Maps

    Point Loma Office Location

    Peninsula Hearing Center, Inc.
    Point Loma Office
    1310 Rosecrans St., Suite A
    San Diego, CA 92106
    Phone: (619) 756-7848
    Fax: (619) 564-7056

    • Our Point Loma Office is located at on the corner of Rosecrans Street and Dickens Street.
    • When traveling WEST on Rosecrans, the office will be on the RIGHT, 8 blocks past Nimitz and directly
      next to a Jack-in-the-Box.
    • We have parking behind the building including one spot designated specifically for PHC patients..
    • If you have any questions, please feel free to contact our office directly.

    Coronado Office Location

    Peninsula Hearing Center, Inc.
    Coronado Office
    230 Prospect Place, Suite 210
    Coronado, CA 92118
    Phone: (619) 756-7848
    Fax: (619) 564-7056

    • Our Coronado Office is located on the corner of C Avenue and 2nd Street.
    • There is parking behind the office with a ramp if needed. There is also public parking on the street.
    • If you have any questions, please feel free to contact our office directly.