America Hears:: Digital hearing Aids

Patient Health History & Medical Waiver
Please fill in all fields marked with a *
	First Name	*
	Last Name	*
	Street Address	*
	City	*
	State	*
	ZIP Code	*
	Date of Birth	*
America Hears "Freedom" hearing aids are suitable for most adults who suffer from diminished hearing due to environment or age. They are not suitable where disease, trauma and or genetic malformation contribute to the loss of hearing, nor are they suitable for children. All of these cases should be taken to an Ear, Nose and Throat medical doctor (E.N.T., MD). In compliance with the FDA and State regulations as well as for your personal protection and answer either YES or NO to the list of physical conditions stated below:
	Visible congenital or traumatic deformity of the ear	*
	Active drainage from the ear within the previous 90 days	*
	Sudden or rapidly progressive hearing loss within theprevious 90 days or a history of this symptom	*
	Acute or chronic dizziness	*
	Surgical or medical procedure(s) involving the ear	*
	Visible evidence of cerumen(ear wax) accumulation or a foreign body in the ear canal	*
	Pain or any discomfort in your ears	*
	Stroke	*
	Any ringing or buzzing sounds in one or both ears	*
	Have you been exposed to any loud noises	*
	Have you recently had a cold or ear infection	*
If you have answered "YES" to any of the conditions listed above, you may be required to provide our company with a medical recommendation form that has been signed by the examining physician within the last (6) months.
I have been advised by * (hearing aid dispenser's name) that the Food and Drug Administration has determined that my best health interest would be served if I had a medical evaluation by a licensed physician (preferably a pbefore purchasing the hearing aid.
By clicking on the "I AGREE" check box below I acknowledge that I do not wish to have a medical evaluation before purchasing a hearing aid, that I understand and agree with the above statements, and that I am 21 years of age or older.
I AGREE *

NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU (AS A CLIENT OF THIS COMPANY) MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION. Please review this notice carefuly by clicking here, and proceed to the agreement below:
I, * have received a copy of the Notice of Privacy Practices.
By clicking the I AGREE check box below, you agree that you have read and agree with the Privacy Policy. I AGREE *

CLIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION AND CLIENT RIGHTS
I hereby give my consent for this company to use and disclose protected hearing health related information (PHI) about me to carry out treatment, payment and hearing healthcare operations (TPO). (The Notice of Privacy Practices provides a more complete description of such uses and disclosures.) I have the right to review the Notice of Privacy Practices prior to signing this consent. This company reserves the right to revise its Notice of Privacy Practices at anytime. A revised Notice of Privacy Practices may be obtained by forwarding a written request to the Privacy Official at 806 Beaver Street Bristol, PA 19007. With this consent, this company may call my home or other alternative location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my hearing healthcare. With this consent, this company may mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and client statements. With this consent, this company may e-mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and client statements. I have the right to request that this company restrict how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement. By signing this form, I am consenting to this company’s use and disclosure of my PHI to carry out TPO. I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, This company may decline to do business with me. Under HIPAA, an individual has the following rights with regard to his/her personal health information (PHI): • The right to authorize the use and disclosure of PHI for certain non-TPO purposes and for psychotherapy notes. • The right to receive a copy of the practice’s Notice of Privacy Practices. • The right to request restrictions on certain uses and disclosures of PHI. • The right to request restrictions on how the practice communicates PHI to the patient. • The right to inspect and copy PHI. • The right to request an amendment of PHI. • The right to an accounting of the disclosures of PHI made by the covered entity for purposes other than TPO and not pursuant to a valid authorization. • The right to complain about alleged violations to the practice and DHHS.
* By confirming your name and clicking "I AGREE," you agree that you have read and understand all of theinformation, terms and conditions set forth above.
I AGREE *