Hearing and Balance Center

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Patient Forms & Insurance

Please print and complete the following forms and bring them with you to your appointment.

Check In Form

Patient Financial Policy

Medical History Page 1
Medical History Page 2
Medical History Page 3
Medical History Page 4

Notice Of Privacy Practices

Acknowledgement Of Privacy Practices

Medication List

Doctor Referral Form


Insurance Accepted

United Healthcare
Anthem BC/BS
Aetna
Connecticare
Tricare
Medicare
Cigna

If you do not see your insurance carrier listed please call and inquire.