FEMALE STREET ADDRESS:


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FULL NAME: ____________________________________________DOB:________________**MALE/FEMALE STREET ADDRESS: _____________________________________ CITY: ________________________STATE:___________ZIP:_____________SSN:__________________________ HOME PHONE:____________________________CELL: _____________________WORK:___________________ EMAIL ADDRESS:__________________________________________ May we contact you via Email? **YES/NO CIRCLE ONE: **MARITIAL STATUS: SINGLE / MARRIED / DIVORCED / WIDOWED/ LEGALLY SEPERATED **EMPLOYMENT: FULL TIME / PART TIME / SELF-EMPLOYED /UNEMPLOYED / RETIRED / STUDENT SPOUSE INFORMATION: NAME:________________________________________________________DOB:____________ SSN:______________________________CONTACT NUMBER:__________________________ EMERGENCY CONTACT NAME:________________________________________NUMBER:__________________ PRIMARY PHYSICIAN:________________________________________________ CLINIC/PRACTICE NAME & ADDRESS:_____________________________________________________________ INS CO:______________________________________ADDRESS:_________________________________________ POLICY / GROUP#:_____________________________________________________ INS CO:_______________________________________ADDRESS:_________________________________________ POLICY / GROUP#:_____________________________ DATE/PRACTICE NAME & ADDRESS LAST TESTED:_________________________________________________ ________________________________________________________________________________________________ HOW DID YOU HEAR ABOUT HEARING & AUDIOLOGY SERVICES? _____________________________________________________________________ Release of information and Assignments of Benefits Declaration I hereby authorize release of any medical information necessary to process my insurance claim and also assign to H.A.S. all payments from my insurance carrier/s rendered. I understand and agree to the above condition. Report will be sent to the primary care physician on file unless otherwise requested.

Signature___________________________________________________ Date_____________________