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NAME: _____________________________

DATE OF BIRTH: ______________________

TODAY’S DATE:_______________________

DIZZINESS AND BALANCE QUESTIONNAIRE

Please fill out the following questions as truthfully and accurately as possible. Our doctors would like to diagnosis your problem as quickly as possible and will use the information on this form to determine what diagnostic tests you may need in order to diagnose your problem.

1. Please describe your symptoms WITHOUT using the word “dizzy” or “vertigo”.

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

2. How many times have you had dizziness or imbalance?

_____ Only once- What date did this occur? __________________________________________________________

_____ More than once. When was the last time it occurred? _____________________________________________

3. How long does your dizziness or imbalance last?

Seconds Minutes Hours Days Continuous

4. Does your dizziness or imbalance occur in relation to any of the following? (Check all that apply)

Activity/Situation: Activity/Situation:

Moving my head Loud sounds

Lying down or looking up Sneezing, blowing nose, or straining

Rolling over in bed Physical activity or exercise

Standing up Eating certain foods

Bending over with head down Menstrual periods (if applicable)

Busy environment or large crowds Other:

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5. Do you have any of the following ear symptoms in addition to dizziness or imbalance? (Check all that apply)

Ear Related Symptoms Right Ear Left Ear

Tinnitus (Ringing, Buzzing, or Humming in the ears)

Ear Fullness or Pain (The ear feels stopped up or hurts)

Hearing Loss

6. Do any of the following non-ear-related symptoms occur with the dizziness or imbalance? (Check all that apply)

Non-Ear-Related Symptoms: Non-Ear-Related Symptoms:

Headache Brain Fog

Facial Numbness Nausea or Vomiting

Numbness or Tingling in my hands or feet Light Sensitivity

Visual Changes Anxiety or Panic Attack

7. Have you ever been diagnosed with any of the following diseases or conditions?

Please Check all that Apply Please Check all that Apply

Meniere’s Disease Heart Disease

Concussion/Head Injury High Blood Pressure

Chronic Middle Ear Disease Parkinson’s Disease

Thyroid Multiple Sclerosis

Diabetes Depression or Anxiety Disorder

Peripheral Neuropathy Seizure Disorders

8. Please describe your level of disability at this time from your dizziness or imbalance?

_____ I am able to work, drive, and feel no ill effects from my dizziness.

_____ I can continue to function with my dizziness but not optimally.

_____ I need to stop when dizzy, but can return to work soon thereafter.

_____ I am incapacitated for extended periods of times because of the dizziness.

_____ I am disabled.

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9. Have you seen any other physician or specialist regarding dizziness or imbalance? ______ If Yes, List below.

Physician When Where Results/Diagnosis/Testing?

10. Did the dizziness or imbalance occur following an accident? _____________ If so list details below:

_______________________________________________________________________________________________

11. Please list medications you are currently taking for your dizziness or imbalance:__________________________

_______________________________________________________________________________________________

12. Who referred you to our practice? _______________________________________________________________

13. Type of Insurance? ______________________________________________________________

MEMBER ID: _____________________________ GROUP #:________________________

BEST PHONE NUMBER TO MAKE APPOINTMENT:

_______________________

PLEASE RETURN COMPLETED PACKET TO:

FAX: 972-566-3883

OR

EMAIL: thehearingcenter@dallasear.com

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7777 FOREST LN #A103 / #A107 DALLAS, TX 75230

REGISTRATION Today’s Date:

Last Name: First Name: Middle:

Birthdate: Age: Gender: M F Social Security #:

Street Address:

City: State: Zip:

Home Phone: Work Phone: Cell Phone:

Email Address:

Pharmacy Name, Location and Phone:

RESPONSIBLE PARTY INFORMATION: (POLICY HOLDER) – IF SAME AS PATIENT CAN SKIP THIS SECTION

Last Name: First Name: Middle:

Relationship to Patient: Birthdate:

Age: Gender: M F Social Security #:

Street Address:

City: State: Zip:

Home Phone: Work Phone: Cell Phone:

Email Address:

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WHO TO CONTACT: I hereby give permission to Dallas Ear Institute to disclose and discuss any information related to my medical condition, appointments, and records to/with the following:

Name: Relationship: Phone:

Name: Relationship: Phone:

Preferred Methods of Contact (circle): Home Phone Work Phone Cell Phone Email Text

May we leave a voicemail with detailed information? Yes No

The duration of this authorization is indefinite unless otherwise revoked in writing. I understand that requests for medical information from persons not listed above will require specific authorization prior to any disclosure of any medical information.

Printed Name of Patient or Legal Representative Date

Signature of Patient of Legal Representative

PLEASE PROVIDE US WITH ALL OF YOUR INSURANCE CARDS (INCLUDING MEDICARE) AND DRIVER’S LICENSE SO

THAT WE MAY MAKE A COPY FOR YOUR FILE. I hereby authorize the release of any medical information in the processing of my claim. I also authorize payment directly to Dr. Peters, Dr. Hahn, and Dr. Dansby for the medical/surgical benefits.

Signature of Patient/Representative Relationship to Patient (if applicable)

NOTICE OF PRIVACY PRACTICES

ACKNOWLEDGEMENT FORM

I acknowledge receipt of this Notice of Privacy Practices which I have reviewed and give my permission to Dallas Ear Institute to use and disclose my health information in accordance with it.

Signature of Patient/Representative Relationship to Patient (if applicable)

_ _ Printed Name of Patient Date

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General None Weight Change / Fatigue / Difficulty Walking Eyes None Glaucoma / Cataracts / Double Vision Heart None High Cholesterol/Hypertension/Heart Attack/Cardiac Disease Lung None Asthma / Snoring / Sleep Apnea / COPD Gastro Intestinal None Ulcers / Reflux Disease / Hepatitis Kidney None Stones / Renal Failure / Prostate / UTI Musculo Skeletal None Arthritis / Fractures / Weakness / TMJ Endocrine None Thyroid / Diabetes Neurological None Migraines / Head Trauma / Stroke / Multiple Sclerosis Immunodeficiency None Seasonal Allergies / Autoimmune / Sinusitis / HIV Psychiatric None Depression / Anxiety / Psychosis Other

CASE HISTORY

Name: Date:

Age: DOB: Gender: M F Occupation:

Primary reason for visit?

Primary Care Physician: Last: First: Location:

Who may we thank for referring you?

MEDICATIONS: Which of the following types of medications have you taken? (Indicate dosage and length of time taking)

Name Amount How Often

ALLERGIES: Are you allergic to any medications? YES NO

If so, which ones:

What type of reaction?

PAST MEDICAL HISTORY: (circle all that apply)

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SURGICAL HISTORY: (including ear surgery): Include type of surgery and date of procedure.

FAMILY HISTORY: What medical problems run in your family (including hearing loss)?

Father:

Mother:

Other:

SOCIAL HISTORY:

Do you smoke? Yes No How many cigarettes per day?

Do you drink alcohol? Yes No If yes, Occasional Moderate Frequent

Do you drink caffeine? Yes No

PRESENT PROBLEM:

Hearing Loss Right Ear Left Ear Duration

Fluctuating Hearing Ear Fullness Ringing/ Tinnitus Ear Infection Better Hearing Ear Hearing Aid Ear Pain

Do you have dizziness? YES NO (If no, skip this section)

If yes, when did it begin?

How long does it last?

How often does it happen?

Is your dizziness: MILD MODERATE SEVERE

I ACKNOWLEDGE THAT THE INFORMATION STATED ABOVE IS TRUE AND COMPLETE:

Printed Name Patient/Guardian Signature Date

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DALLAS EAR INSTITUTE Thank you for choosing us as your health care provider. We are committed to your treatment being successful. Please understand that payment of your bills is considered a part of your treatment. The following is a statement of our financial policy, which we require you to read, agree to and sign prior to any treatment. Dr. Peters, Dr. Hahn and Dr. Dansby render only services that, in their best professional judgment, is needed to provide quality medical care for you.

PAYMENT IS DUE AT THE TIME OF SERVICE We accept cash, checks, Visa, MasterCard, American Express

REGARDING INSURANCE

Our office is pleased to assist you in filing claims with your insurance company for reimbursement of these expenses. We will wait 45 days for your insurance company to pay your claim and if they do not we will give you 30 days to pay the balance. If your account becomes outstanding, it will be sent to a collection agency and 40% will be added to the balance.

• The patient is responsible to pay any deductible and co-payments at the time services are rendered.• It is your responsibility to know if a referral is necessary for your visit and obtain prior to your

appointment if needed. If a referral is required and not present at the time of your visit, you maychoose to see the doctor and pay for your visit at that time or reschedule once the referral is obtained.

• Any portion of a billed amount that is labeled “disallowed” or “not covered” will become the patient’sresponsibility.

• Our office NEVER guarantees that your insurance will pay. We will make every attempt at thebeginning of your health care to receive verification of your policy benefits. However, if for somereason your insurance claim is denied, you are responsible for the amount due on your account.

• Your insurance is a contract between you, your employer, if a group policy, and the insurancecompany. We are not a party to that contract. While we have an agreement with the Health Plan toprovide services, any questions regarding coverage must be resolved by you with the insurancecompany.

• Not all services are a covered benefit in all contracts. Some insurance companies arbitrarily selectcertain services they will not cover.

USUAL AND CUSTOMARY RATES: Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company’s determination of usual and customary.

CHARGES FOR EQUIPMENT/HEARING DEVICES: The total cost of equipment is due at the time the equipment is fitted/received. You will be reimbursed any amount covered by your insurance. However any portion of the device(s) or equipment that is not paid by insurance ( “disallowed”, “not covered”, “provider discount”, etc.) will become your responsibility.

NSF CHECKS: All returned checks will be assessed a $36.00 fee. All returned checks not paid in 15 days will be filed with the proper authorities.

Thank you for understanding our financial policy. Please let us know if you have any questions or concerns.

I have read, understand and agree to the provisions of this financial policy.

Signature of patient or person responsible for the bill Date

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Notice of Privacy Practices THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. THIS IS REQUIRED

BY THE PRIVACY REGULATIONS CREATED AS A RESULT OF THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (HIPAA).

PLEASE REVIEW IT CAREFULLY.

Dallas Ear Institute is committed to maintaining the privacy of your health information and has therefore adopted the following privacy policies.

Uses and Disclosures of your Protected Health Information not requiring your consent.

Treatment: Your health information may be used by the staff of Dallas Ear Institute and/or disclosed to other healthcare professionals for the purpose of evaluating your health, diagnosing your medical conditions, and providing the necessary medical treatment. For example, results of laboratory testing and/or our treatment of your medical conditions will be available in your medical records to any healthcare professional who may provide treatment.

Payment: Your health information may be used to obtain payment from your health plan, credit card companies that you may use to pay for services, or from other sources of payment such as a collections agency. For example, in an effort to get payment from your health plan, they may request and receive information on dates of service, services provided, and medical conditions being treated.

Healthcare Operations: Your protected health information may be used to support the day-today activities of Dallas Ear Institute. For example, we may use your diagnosis, treatment, and outcome information to measure the quality of the services we provided or to assess how effective our treatment was when compared to our other patients in similar situations.

Legal Authorities: In some situations, our staff may be required to disclose your health information to legal authorities, such as law enforcement officials, court officials, or government agencies. For example, we are required by law to report abuse, neglect, domestic violence, or certain physical injuries.

Public Health Officials: Your health information may be disclosed to public health agencies that are authorized by law. For example, all healthcare professionals are required to report certain communicable diseases to the State Health Department.

Additional uses that do not require your consent.

Correspondence: Your health information will be used by the staff of Dallas Ear Institute to remind you of upcoming appointments. We may also send you information about goods available for treatment of your medical condition that we feel you may find to be of interest.

Activities related to death: Your health information may be disclosed to a coroner or medical examiner for the purpose of completing a death certificate or investigating a death.

Worker’s Compensation: If applicable, your health information may be shared for any Worker’s Compensation claim that is reasonably related to any injury. Any other use or disclosure of your protected health information will REQUIRE WRITTEN AUTHORIZATION. (If necessary, please ask the receptionist for the appropriate form).

Dallas Ear Institute will make every effort to maintain the privacy of your health information. We are required by law to not only provide you with this notice of privacy practices, but to abide by the content outlined in this notice.

Your rights regarding your protected health information.

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1. the right to request restrictions on the use and disclosure of your health information; 2. the right to receive confidential communications among our staff related to your medical conditions and treatment; 3. the right to review and copy your health information, with the exception of psychotherapy notes; 4. the right to make changes to your health records 5. the right to receive a written listing of how, to whom, and why your protected health information has been disclosed since April 14, 2003; 6. the right to request and receive a printed copy of this notice. Our rights regarding your health information 1. As permitted by law, Dallas Ear Institute reserves the right to amend or modify our privacy policies and practices. Such changes may be required by federal and state regulations, and we will provide you with a revised notice on your next office visit. 2. Dallas Ear Institute reserves the right to require written request from you to inspect or copy your health information. If you feel like your privacy rights have been violated or you would like to submit a comment, please do so by sending a letter to:

Sarah Jenson-Wallace, R.N. Clinic Director Dallas Ear Institute 7777 Forest Lane, Ste. A-103 Dallas, TX 75230

Patient  Appointment  Agreement  for  Audiology  Services  

Thank  you  for  choosing  The  Hearing  Center  at  Dallas  Ear  Institute  for  your  hearing  healthcare  needs!      

Due  to  the  personnel  resources  and  time  commitment  needed  to  provide  the  complex  services  offered,  it  is  imperative  that  our  patients  be  very  faithful  in  keeping  their  scheduled  appointments.    We  understand  that  unforeseen  events  occur  that  require  last  minute  cancellations  of  appointments.    However,  Dallas  Ear  Institute  cannot  be  expected  to  bear  the  financial  loss  that  occurs  when  this  reserved  appointment  time  goes  unutilized.      

In  order  to  ensure  your  commitment  to  reserving  our  time  to  provide  these  services,  we  are  informing  you  up  front  that  you  will  be  billed  a  $150  cancellation  fee  if  you  cancel  within  less  than  two  (2)  business  days  notice  or  do  not  show  up  for  your  scheduled  appointment,  except  in  the  event  of  a  true  emergency.    This  is  a  charge  that  your  insurance  company,  Medicare  or  Medicaid  will  not  cover.    Payment  of  the  cancellation  fee  will  be  due  prior  to  rescheduling.  

Thank  you  very  much  for  your  cooperation.  

________________________________________________________  Printed  Patients  Name  

________________________________________________________   _________________________________  Signature  of  person  financially  responsible   Date  

DALLAS EAR INSTITUTE

Thank you for choosing us as your health care provider. We are committed to your treatment being successful. Please understand that payment of your bills is considered a part of your treatment. The following is a statement of our financial policy, which we require you to read, agree to and sign prior to any treatment. Dr. Peters, Dr. Hahn and Dr. Dansby render only services that, in their best professional judgment, is needed to provide quality medical care for you.

PAYMENT IS DUE AT THE TIME OF SERVICE We accept cash, checks, Visa, MasterCard, American Express

REGARDING INSURANCE Our office is pleased to assist you in filing claims with your insurance company for reimbursement of these expenses. We will wait 45 days for your insurance company to pay your claim and if they do not we will give you 30 days to pay the balance.

• The patient is responsible to pay any deductible and co-payments at the time services are rendered. • It is your responsibility to know if a referral is necessary for your visit and obtain prior to your appointment if

needed. If a referral is required and not present at the time of your visit, you may choose to see the doctor and pay for your visit at that time or reschedule once the referral is obtained.

• Any portion of a billed amount that is labeled “disallowed” or “not covered” will become the patient’s responsibility.

• Our office NEVER guarantees that your insurance will pay. We will make every attempt at the beginning of your health care to receive verification of your policy benefits. However, if for some reason your insurance claim is denied, you are responsible for the amount due on your account.

• Your insurance is a contract between you, your employer, if a group policy, and the insurance company. We are not a party to that contract. While we have an agreement with the Health Plan to provide services, any questions regarding coverage must be resolved by you with the insurance company.

• Not all services are a covered benefit in all contracts. Some insurance companies arbitrarily select certain services they will not cover.

USUAL AND CUSTOMARY RATES: Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company’s determination of usual and customary. CHARGES FOR EQUIPMENT/HEARING DEVICES: The total cost of equipment is due at the time the equipment is fitted/received. You will be reimbursed any amount covered by your insurance. However any portion of the device(s) or equipment that is not paid by insurance ( “disallowed”, “not covered”, “provider discount”, etc.) will become your responsibility. NSF CHECKS: All returned checks will be assessed a $36.00 fee. All returned checks not paid in 15 days will be filed with the proper authorities. Thank you for understanding our financial policy. Please let us know if you have any questions or concerns. I have read, understand and agree to the provisions of this financial policy. Signature of patient or person responsible for the bill Date