Hearing Aid Benefit Check

Date
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dd-MMM-yyyy
Are you or the person you are submitting a request for a resident of Middle Tennessee? *
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Name
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Required First Required Last
Date Of Birth: *
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Insurance Carrier: *
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Insurance Company Name
ID Number: *
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Phone: *
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Have you had a hearing test in the last year?
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If you have a copy of your most recent hearing test, upload it here:
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Upload file
Email
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Terms and Conditions *
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Privacy Policy. Nashville Hearing Specialists will not share or sell any of your personal information. CONFIDENTIALITY NOTICE: This transmission is covered by the Electronic Communications Privacy Act, 18 U.S.C. 2510-2521 and may contain HIGHLY CONFIDENTIAL Personal Health Information (PHI) or other confidential or legally privileged information, intended for the exclusive use of the individual or entity named in the e-mail address. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or reliance upon the contents of this e-mail is strictly prohibited and may constitute a violation of Federal Law (HIPAA) and will be reported as such. If you have received this e-mail transmission in error, please notify Sender immediately by telephone at (615) 244-1229, and delete the message from any and all machines.

I accept the Terms and Conditions.

Hearing Aid Benefit Check Request