{"id":396,"date":"2016-08-01T16:26:32","date_gmt":"2016-08-01T16:26:32","guid":{"rendered":"https:\/\/accuratehearingsystems.com\/?page_id=396"},"modified":"2026-05-05T08:00:10","modified_gmt":"2026-05-05T08:00:10","slug":"consent-for-treatment","status":"publish","type":"page","link":"https:\/\/accuratehearingsystems.com\/?page_id=396","title":{"rendered":"Consent for Treatment"},"content":{"rendered":"<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of 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gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_8_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_8_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_8_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_8_2\" class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Parent\u2019s\/Guardian Name if Patient is a Minor<\/label><div 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class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\"><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_8_5_1_container'>\n                                            <input type='number' maxlength='2' name='input_5[]' id='input_8_5_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_8_5_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_8_5_2_container'>\n                                            <input type='number' maxlength='2' name='input_5[]' id='input_8_5_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_8_5_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_8_5_3_container'>\n                                            <input type='number' maxlength='4' name='input_5[]' id='input_8_5_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_8_5_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/div><\/li><li id=\"field_8_6\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_6'>Work Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_6' id='input_8_6' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_8_7\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_7'>Home Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_7' id='input_8_7' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_8_8\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_8'>Cell<\/label><div class='ginput_container ginput_container_phone'><input name='input_8' id='input_8_8' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_8_9\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_9'>Referred By<\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_8_9' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_8_10\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >We appreciate the opportunity to assist you in your pursuit of better hearing and promise to provide quality service in any way we can. Although we are happy to work with your insurance provider, patients are ultimately responsible for their bill. In most cases, payment is required at time of service.\n<\/p>\n<strong>Please note: Medicare does not provide coverage for hearing aids, batteries, or repairs.<\/strong>\n<\/p>\n<strong>Consent for treatment:<\/strong>\nBy signing below, I give my consent for examination and treatment for myself. If patient is a minor, by signing I give consent for examination and treatment for the above minor patient.\n<\/p>\n<strong>Consent for Use and Disclosure of Protected Health information:<\/strong>\nI hereby give my consent for Accurate Hearing Systems, LLC to use and disclose of protected health information (PHI) about me to carry out treatment, payment and health operations. (The Notice of Privacy Practices provided to me describes such uses and disclosures more completely).\n<\/p>\nI have the right to review the Notice of Privacy Practices prior to signing this consent. 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