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AUDIOLOGICAL REFERRAL FORM TO BE COMPLETED BY PHYSICIAN FAX FORM TO 510-848-4801 ATTN: AUDIOLOGY Patient Date of Referral Date of Birth Parents Name Physician Home Address Hospital/Clinic Physician

How to fill out audiological referral form

How to fill out an audiological referral form:

1. Begin by entering your personal information, such as your full name, date of birth, and contact details. This ensures that the audiologist can properly identify and reach out to you.
2. Provide information about your primary care physician or referring doctor. Include their name, contact information, and any relevant medical history or conditions that they may be aware of.
3. Indicate your reason for seeking audiological evaluation. Whether it is hearing loss, tinnitus, or any other specific concern, make sure to accurately describe your symptoms and their duration.
4. Specify any previous audiological tests or evaluations you may have undergone. Include the dates, the names of the professionals who conducted the tests, and any relevant results or diagnoses they provided.
5. If you have any existing medical conditions or are taking medications that may impact your auditory health, disclose this information in the form. Examples may include diabetes, cardiovascular disease, or medications known to have ototoxic effects.
6. List any allergies or sensitivities you have, especially if they are related to audiological testing procedures or equipment. This is important for the audiologist to know to ensure your safety and comfort during the evaluation.
7. Include any insurance information if applicable. This may involve providing your insurance company's name, policy number, and any necessary authorization or prior approval numbers.
8. Finally, sign and date the audiological referral form to acknowledge that the information provided is accurate to the best of your knowledge.

Who needs an audiological referral form?

An audiological referral form is typically required for individuals who are seeking a professional evaluation of their hearing or experiencing auditory concerns. This may include those who have noticed a decline in their ability to hear or individuals who are experiencing ringing or buzzing sensations in their ears (tinnitus). Additionally, individuals who have been referred by their primary care physician or a specialist, such as an otolaryngologist, may also need to fill out an audiological referral form.

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What is audiological referral form?

The audiological referral form is a document used to refer someone to an audiologist for evaluation of hearing issues.

Who is required to file audiological referral form?

Medical professionals such as doctors, nurses, or speech therapists may be required to file the audiological referral form.

How to fill out audiological referral form?

The audiological referral form typically requires the patient's personal information, medical history, and reason for referral. It may also include the referring medical professional's contact information.

What is the purpose of audiological referral form?

The purpose of the audiological referral form is to facilitate communication between healthcare providers and ensure that patients receive appropriate evaluation and treatment for hearing issues.

What information must be reported on audiological referral form?

The audiological referral form may require information such as the patient's name, date of birth, medical history, reason for referral, and any relevant test results.