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First Visit

SAVE TIME. BE PREPARED.

The form below and the forms to be completed in the left sidebar are all HIPAA compliant.  For your convenience and safety we will have you complete these forms prior to your (first) visit.  (But do not worry if you forget – you can always complete them at the office as well). Your information will remain completely private and protected and only be viewed by your physician and appropriate and credentialed staff at Acoustic Hearing Center.

 

Directions:  Print & complete the attached forms for your visits and/or treatment.  Complete all applicable fields and bring with you to your appointment. 

Click below to open PDF.  Print & Complete

(4:2021) Patient-Information-Form

 

 

Click below to open PDF.  Print & Complete

Adult Hearing Health Profile

Please DO NOT Complete this form until the day of your appointment  

 

Click below to open PDF.  Print & Complete

Covid Questionnaire

 

Hello!

Accepted Insurances

AETNA

EMPIRE PLAN NYSHIP
GHI/EMBLEM
HUMANA
MAGNACARE (LOCAL3 and UFT)
MEDICARE

*We accept most
Federal & State insurance plans.

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