Privacy Notice & Patient Forms

EAR Audiology is committed to maintaining patient privacy. Every patient is asked to read and sign the Privacy Notice and Financial Policies documents below prior to their first appointment. New patients with Medicare are also asked to sign the Assignment of Benefits and Release of Information to Medicare form. In addition, patients are asked to complete the patient history form, as well as the tinnitus and dizziness questionnaires if applicable, for discussion at their first appointment.

1. Privacy Notice
2. Financial Policies
3. Assignment of Benefits & Release of Information to Medicare
4. Patient History
5. Intra-office New Patient Check-in
6. Tinnitus Questionnaire
7. Dizziness and Imbalance Questionnaire
8. FDA Notice and Medical Exam Waiver Statement
9. Hearing Aid Evaluation
10. California Telephone Access Program

EAR Audiology is happy to assist physicians with the identification of patients in need of audiologic evaluation. The screening forms below are useful, easy-to-administer, evidence-based tools for physicians to rapidly identify patients needing referral. Physicians are also encouraged to administer hearing and balance screenings as part of the Welcome to Medicare one-time preventative examination.

1. Hearing Handicap Inventory for the Elderly (HHIE)
2. Dizziness Handicap Inventory (DHI)
3. Tinnitus Handicap Inventory (THI)
4. Review of Systems Questionnaire
5. Medical Clearance for Hearing Aids
6. Tinnitus 101
7. EAR Audiology promotional flyer

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