Patient Forms

Whether you are a new or existing patient, Alexiou Hearing & Sinus Center requires a small effort on your part so that we can meet the many needs of an integrated healthcare system. You may bring your forms to your appointment or email them to our secure email at [email protected]

Patient Registration Form

Forms to be completed annually:

• PHI Annual Demographic Information Form (Protected Health Information) – To protect your privacy, Alexiou Hearing and Sinus Center will NOT discuss your information (medical or financial) with any parties who are NOT listed.
  PHI ANNUAL DEMOGRAPHIC INFO
• Patient Agreement – The intent of this agreement is to inform you of Alexiou Hearing & Sinus Center’s financial policies and Notice of Privacy Practices (HIPAA).
  Patient Agreement
• Health History Form – The providers require this form to better understand your medical history for potential treatment. ONLY required for NEW PATIENTS or if you have not been seen in 3 years.
  Health History Form
  

Forms to be completed as needed:

• Request for Medical Records Release Form – Whether you are requesting forms be sent to another provider or requesting forms be sent to Alexiou Hearing & Sinus Center, your written authorization is required.
  Medical Release Form
• Consent to Treat a Minor – A parent or guardian must accompany all patients under 18 during the initial visit.
  Consent to Treat a Minor