Insurance intake form

Please fill in the form

Click here to review and download .pdfs of the Billing Service Recipient Bill of Rights and Responsibilities, DME POS Supplier Standards, release of information, Notice of Privacy Practices and Billing Service description

In addition to the online forms, we will also need the additional information to be sent in to us at either InsuranceServices@oticonmedical.com or faxed to 888-683-8736. Please note we cannot begin working on a request until all paperwork has been received:              

From the Patient:
- Copies of your insurance card

From the ENT/Audiologist:
- Signed physician order
- Most recent, relevant clinical notes
- Most recent audiogram

 

Patient Information
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Gender
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Side implant
Insurance Information
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Type of Insurance Plan
Secondary Insurance Information
Type of Insurance Plan
Clinic Information
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By checking this box, I signify that this will serve as my electronic signature on these forms. This also serves as my acknowledgement/receipt of the Billing Service Recipient Bill of Rights and Responsibilities, DME POS Supplier Standards, release of information, Notice of Privacy Practices and a Billing Service description. I have received the product manual/instructions and warranty information, if applicable.

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