New Patient Information Packet

Transcription

1 New Patient Information Packet Thank you for scheduling your appointment with our North Scottsdale office. We look forward to meeting you! We find it can be helpful to bring a friend or family member whose voice you are used to, to this appointment. Please take a moment and complete the enclosed papers and bring them with you to your appointment. If you have any questions, please call our office at Thank you! Cathy E. Kurth, Au.D., FAAA, Doctor of Audiology and the Audiology and Hearing Aid Center Team Audiology and Hearing Aid Center 9777 N. 91st Street, Suite 101 Scottsdale, AZ Phone: (480) Fax: (480)

2 Welcome! We are very excited to meet you at your upcoming appointment at our office. There is a detailed map included in this 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 a half an hour. During that time, your audiologist will take a thorough history of your situation. If necessary, they will perform a hearing test while you sit comfortably in a sound booth to listen for various tones and words. They 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 will make a medical referral to a doctor or work with you on selecting the most appropriate hearing system. At the Audiology and Hearing Aid Center, 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!

3 Our Audiologists All of us at Audiology and Hearing Aid Center appreciate your interest in our services and support. We have been assisting people all over Arizona with their hearing health and hearing aid needs for over 36 years. It is our goal to keep you informed of the latest changes and the most current technology offered in the hearing health arena. We want you to have a place you can trust, you can learn from and you can growth with and we hope that Audiology and Hearing Aid Center is just that place! Cathy Kurth, Au.D, FAAA, Doctor of Audiology A true Midwesterner, Cathy grew up in Glenview, Illinois. She opened the Audiology and Hearing Aid Center in 1981 in downtown Scottsdale and since then, she opened offices in North Scottsdale and the Grayhawk area. Cathy has been practicing audiology for more than 25 years. She received her Doctor of Audiology in 2002 from the Arizona School of Health Sciences, a division of A. T. Still University of Osteopathic Medicine. She earned her Bachelor s degree at Loyola University in Chicago and her Masters of Audiology from the University of Illinois. As an expert in her field, she has spoken extensively on hearing healthcare, hearing technology, and the treatment of hearing disorders. Cathy also provides audiological consultation to many doctors in the area. She is licensed by the State of Arizona and clinically certified by the American Speech-Language-Hearing Association (ASHA). She is also a member of prestigious organizations such as the Academy of Dispensing Audiologists, and a fellow of the American Academy of Audiology. Cathy received her Board Certification from the American Academy of Audiology. Through her memberships, she maintains the highest level of knowledge, education, and familiarization with hearing loss, emerging hearing aid technologies, and the changing needs of hearing-impaired patients. In November of 2012, Cathy was awarded The Leo Doerfler Award. This award honors an audiologist who has demonstrated outstanding clinical services in the community and throughout their career. The Leo Doerfler Award is the Academy of Doctors of Audiology s most prestigious professional recognition and supports ADA s mission to advance practitioner excellence, high ethical standards, professional autonomy and sound business practices in the provision of quality audiologic care.

4 Akila Prasad, Au.D., Doctor of Audiology Dr. Prasad was born and raised in Ahwatukee/Tempe, Arizona. A wildcat at heart, she earned her Bachelor of Science degree at the University of Arizona in Tucson. In May of 2013, she left sunny Arizona and made her way to central Illinois, where she received her Doctor of Audiology degree at the University of Illinois at Urbana- Champaign. During her time at U of I, she served as Vice President of the Student Academy of Audiology, and led presentations on hearing loss, hearing loss treatment, and hearing conservation, both on and off campus. After living in the Midwest for 3 years (and experiencing what winter truly feels like), she moved back home to Phoenix, where she completed her 4th year clinical externship in a Neurotology setting. She is very interested in diagnostics and enjoys being up to date on all the latest hearing aid technology and hearing loss treatment solutions. She is a member of the American Speech-Language-Hearing Association, and joined Audiology and Hearing Aid Center in May of Dr. Prasad is passionate about the field of Audiology as a whole, and is extremely excited to be working with all the wonderful patients and providers at the practice. Gina Contrucci, Au.D., Doctor of Audiology Dr. Gina Contrucci graduated from Texas Tech University Health Sciences Center in May 2017 where she acquired clinical experience in a variety of settings, including private practices, ENT offices, an outpatient balance clinic, aural rehabilitation groups, and a public school system. Gina was born and raised in a suburb outside of Milwaukee, Wisconsin and received her undergraduate degree from the University of Wisconsin- Whitewater with a minor in Spanish. Her family including her one younger brother now lives in downtown Chicago. She and her husband, Tony, as well as their two rescue cats moved to Arizona from Texas in the summer of When not helping people hear better, Gina enjoys traveling, listening to music, going to the movies, shopping, and eating out at renowned restaurants around town. Rachel Waite, M.S. Rachel Sandomir-Waite holds Bachelors and Master s degrees from Arizona State University, and is a member of the American Speech-Language and Hearing Association. She has been a Clinical and Dispensing Audiologist for nearly 21 years, and has practiced in a variety of clinical settings, from private Audiology practice, to private Ear, Nose and Throat physician practice, to multi-specialty clinical practice. Rachel has provided Audiologic and Rehabilitative services to a wide range of patient populations, including adult, pediatric, special-needs, cochlear implant, and vestibular patients. Her professional experience includes the privilege of teaching undergraduate and graduate level students in the subjects of Vestibular Assessments and Disorders, Anatomy & Physiology, and Pathophysiology. She is excited to be pursuing her Doctorate in Audiology with the University of Florida, and joined the Audiology and Hearing Aid Center in June, Rachel enjoys her time with her husband and three children, her home-zoo of three cats, two guinea pigs, two rats, and a new German Shephard puppy, and her hobby as an amateur astronomer. Mark Baker Mark Baker grew up in Colorado and moved to Arizona to attend ASU. Although he loves the desert, Mark still loves the mountains and all of the adventures you ll find in them. Mark is a proud father of 2 great teenagers and enjoys family and outdoor activities; including hiking, mountain biking, ATV riding and camping. Mark is a licensed hearing aid dispenser. He has been in the field of Audiology for over eleven years working with ENT s and Audiologists specializing in audiometric testing, and hearing aid fittings. Mark enjoys helping people hear better and accommodating them with the best technology available today.

5 Patient Information Form Patient s Name: Sex: M F Birthdate: Address: Apt# City: State: Zip: Please indicate the primary phone number to use by putting an X in the box next to the appropriate number. We will call this number first when trying to reach you. Home Phone: Work Phone: Cell Phone: Marital Status: Married Single Widowed Divorced Spouse Name: * Address: Insurance Company: Occupation: (past/present) How were you referred to us? Primary Care Physician: Employer: If Doctor or Friend, please write down their name so we may thank them! Responsible Party/Insurance Subscriber: Name: Relationship to Patient: DOB: Address: Apt# City: State: Zip: Home Phone: Work Phone: Cell Phone: *Because we strive to keep our patients informed and updated, we send out periodic s to let you know what is going on in the Hearing Healthcare Arena. Since we are as concerned about your privacy as you are, we will not share your address with any other entity, for any reason. It will remain secured in our system. Your signature indicates that you have read the information on this sheet, and all information you have provided is free from errors. This will also serve as a on File for any insurance claims and/ or payments made on your account. Date Date Date Date Date

6 Patient s Name: Date: Please complete each section. HEARING HISTORY Have you ever had a hearing test before? No Yes If yes, when? Do you have noises in your ears? (Tinnitus) No Yes If yes, Right Left Both ears Do your ears feel plugged? No Yes If yes, Right Left Both ears Does earwax ever cause a hearing problem? No Yes If yes, Right Left Both ears Do you ever experience dizziness or Vertigo? No Yes If yes, please explain Is there a history of hearing loss in your family? No Yes Have you ever been exposed to loud noises? No Yes Did your hearing loss happen suddenly? No Yes Which ear hears better? Left Right No difference What do you think caused your hearing loss? Why have you decided to get your hearing tested at this time? I feel my hearing is poor and may need to be aided. No Yes Family/friends have suggested I have my hearing checked. No Yes Other reason/please explain: How is your general health? Have you ever had chronic ear infections? No Yes Have you ever had ear surgery? No Yes If yes, when? Which ear? Left only Right Only Both ears What procedure? Have you ever had trauma to the head? No Yes Do you have sinus or allergy problems? No Yes Do you ever have pain in your ears? No Yes Do you ever have drainage from your ears? No Yes To your knowledge, have you ever punctured an eardrum? No Yes Have you consulted a physician regarding your hearing problem? No Yes Have you had or currently have any of the following: High Blood Pressure Arthritis Cancer Meningitis Heart Disease Diabetes MEDICAL HISTORY YES NO YES NO Mumps General Anesthetic Stroke Kidney Disease Measles AIDS/HIV Please list any medications that you take, including over-the-counter:

7 HISTORY OF COMMUNICATION PROBLEMS Please answer these questions and bring them with you to your appointment. They will help your hearing care professional better understand your needs. It may also help if you can talk these over with your family and friends. 1. Do you think that you have a hearing loss? Please explain. 2. In which situations have you experienced challenges with your hearing? 3. Has your hearing been frustrating you? 4. Have your family members or friends mentioned anything about your hearing? 5. If your hearing was improved, how would things be different for you? 6. Please write down any questions you have about your hearing. 7. Would your spouse, family member or friend like to make any comment? HEARING AID HISTORY Do you already have hearing aids? No Yes If yes, please indicate: Left only Right only Both ears What year did you buy your hearing aids? Do you wear them regularly? No Yes How many hours per day? What problems are you experiencing with your hearing aids (check all that apply): Some sounds are too loud Things sound tinny Hearing aid whistles Wind noise My ears feel plugged up My voice sounds hollow I can t understand in noise Telephone is difficult I can t tell where sounds are coming from

8 Patient Financial Policy for Audiology and Hearing Aid Center Patient s Name: DOB: As a patient, you agree to pay for all portions 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 are contracted with most major insurances and will bill these carries 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. Medicare: Our office is a Medicare participating provider and we will bill Medicare for you. Medicare only covers a complete hearing evaluation if referred by a physician. Referrals/scripts are due at the time of the appointment and are your responsibility to obtain. Hearing aids are not a covered benefit. Any outstanding balances and deductibles are due at your appointment. Any non-covered service will be due as service is rendered. 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, credit cards, and patient financing options for those patients who qualify. Date:

9 Patient Privacy Notice (HIPAA) 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 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 Audiology and Hearing Aid Center. 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 , 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 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 Audiology and Hearing Aid Center s Notice of Privacy Practices. Date:

10 How to Find Us! 91st Street Office North Scottsdale Shea Blvd. Mountain View NORTH th St. Via Linda 91st St. In Suite 101 Mountain View Office Suites Exit 42 off N. 91st Street, Suite 101 Scottsdale, AZ Telephone: (480) Fax: (480) How To Find US - From the 101 Freeway If traveling on the 101 Freeway, take the Shea Blvd exit and go east. At the light at 90th Street, go south to Mountain View Road. At Mountain View Road, go east to 91st Street. Go south on 91st Street and take your first left at the Mountain View Offices Suites. Our office is located in Suite 101, in the second building on the right.