Insurance intake form ENT


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

 

Physician Information
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Audiologist Information
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Service request
Request


Model Qty.
Side (Ponto 3 SP only)

Colors
Color of processor










Free Accessory
Please choose



Softband
Please choose

Procedures Information
Place of service


Side of implant


Medical Information Section A
Medical Information Section B
Patient Information
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Gender