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Patient Intake Form

Patient Intake Form

  • CONSENT TO USE OR DISCLOSE PROTECTED HEALTH INFORMATION FOR TREATMENT, PAYMENT, HEALTHCARE OPERATIONS AND OTHER LIMITED PURPOSES



    I understand that as part of my healthcare, Audicles Hearing Services, and more specifically the healthcare services and clinics where I obtained medical care, create, receive, and maintain personally identifiable health records about me that describe my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. This information is referred to as “protected health information” or PHI. I understand that Audicles Hearing Services is permitted under HIPAA to use and disclose my PHI without my consent or authorization for certain specific purposes like treatment, payment, and healthcare operations as well as for certain other limited purposes specified in HIPAA and described in the Notice of Privacy Practices offered to me at or about the time I first received care here. A copy of the Notice of Privacy Practices will be provided to me at any time upon my request.

    I hereby consent to allow Audicles Hearing Services and more specifically its healthcare services and clinics where I obtained medical care to use or disclose my PHI under that law for treatment, payment, healthcare operations, and other limited purposes as permitted by HIPAA, as described to me above and in the Notice of Privacy Practices. In granting my consent, however, I am not waiving any rights I may have or relieving Audicles Hearing Services of any obligations it may have under any other applicable federal or state laws relating to medical information privacy that are stricter than (and therefore, not preempted by) HIPAA.

    I hereby consent to evaluation, testing, and treatment as directed by Audicles Hearing Services.
  • Authorization for Marketing Services and Products



    From time to time, Audicles Hearing Services would like to tell you about products and services that we think may be of interest to you. When we give patients promotional gifts of nominal value or recommend products or services in face-to-face communication, we do not require written authorization. However, we do require written authorization before sending other kinds of marking communications if Audicles Hearing Services receives financial remuneration for sending the communications.

    If you would like to receive information about products and services from Audicles Hearing Services, please complete and sign the authorization below:

    I hereby authorize Audicles Hearing Services to use my name and address and other information about my health to provide marketing communications to me. I understand that Audicles Hearing Services may receive financial remuneration for making marketing communications.

    I understand that I may revoke this authorization at any time, and that my revocation is not effective unless it is in writing and received by the Privacy Official at the following address:

    Audicles Hearing Services
    901 NE Loop 410, Ste. 410
    San Antonio, Texas 78209