3271 N. Civic Center Plaza, Suite 4 Scottsdale, AZ VNG Testing

Transcription

1 3271 N. Civic Center Plaza, Suite 4 Scottsdale, AZ VNG Testing Thank you for scheduling your appointment with our office. We look forward to seeing you! We cannot stress more, how important it is that you follow the instructions on the following sheet of paper. If you need to cancel or reschedule, please due so within 24 hours prior to your appointment date or an office visit fee of $65.00 will be assessed. VNGs are scheduled for 2 ½ hrs and when a patient cancels with short notice, we are not able to fill that 2 ½ hour gap in an efficient amount of time. The accuracy of the test is dependent on you following the instructions accurately. Please read the information regarding medications carefully. Your cooperation is greatly appreciated! If you have any questions or concerns about the test, please feel free to contact us at: (480) Sincerely, Audiology and Hearing Aid Center

2 Patient Information and Instruction Sheet The Balance Clinic at Audiology and Hearing Aid Center 3271 North Civic Center Plaza, Suite 4 Scottsdale, AZ Procedure Description Posturography is simply a test of your ability to maintain balance. During the test, you will be required to stand quietly on a hard or soft platform and asked to open or close your eyes for brief periods of time. The computer will automatically record your test responses. There is nothing attached to your body while you are performing this test. The procedure is effortless and painless and takes only about minutes. Videonystagmography (VNG) is a test to evaluate your inner ear balance system. Through this test, we can determine how effective the inner ear balance system is functioning by measuring your eye movements. During the test, you will be wearing VisualEyes (specialized goggles) that fit comfortably over your eyes and record your eye movements on the computer. Results will be displayed on the monitor so you can see for yourself how the test is progressing. There are three main parts to the VNG. First, while you are seated and wearing the goggles, you will be asked to watch a series of dots as they appear up and down a light bar located in front of you. Next, you will be asked to turn your head in several different positions. Finally, your ears will be irrigated with low pressure, warm and cool air to measure back-and-forth eye movements. This is called nystagmus. The test is not painful; however, you may feel at times as if the room is spinning. This should only last a few minutes. The complete test lasts approximately one and a half hours. Pre-Evaluation Instructions Get plenty of rest the night before the appointment Wear comfortable, loose-fitting clothing Do NOT drink alcoholic beverages for at least 24 hours before testing Do NOT drink any caffeinated beverages, including decaffeinated coffee or soft drinks such as soda or pop, prior to your scheduled evaluation Do NOT wear makeup to the evaluation (The goggles worn during VNG testing are very sensitive). Makeup will affect the computer s recording of eye movement data). Please do NOT eat or drink anything for at least three hours prior to your VNG evaluation. (If you are diabetic or hypoglycemic, please eat a light snack instead of skipping a meal). If possible, have someone drive you to and from your evaluation appointment. You may experience a minor sensation of dizziness or imbalance during some portions of the test and for a short amount of time after the test. These symptoms are necessary to providing us with valuable information about your condition. If you do not have a driver, we may ask you to relax in the waiting room for a few minutes until the dizziness subsides. IMPORTANT: Certain medications may change the findings of the VNG evaluation. We ask that you NOT take any NONESSENTIAL medications for a period of 48 hours before your scheduled appointment time, and that you especially avoid the following: Sleeping pills Tranquilizers Anti-dizziness pills Antihistamines Narcotics of any kind Over-the-counter cold or allergy medicine Medications that contain any of the above IMPORTANT: Please consult your physician before discontinuing any prescribed ESSENTIAL medications. If you have questions, please contact the Balance Clinic at (480)

3 Who You Will Be Seeing for Your VNG Test Chris Cummins-Beagle, M.S., FAAA, Clinical Audiologist, grew up in Phoenix and calls the Valley of the Sun her home. She has been practicing Audiology since 1987 after graduating from the University of Texas at Dallas with a Master s of Science degree in Audiology. She received her Bachelor s of Science degree in Communication Disorders, graduating Magna Cum Laude, from Northern Arizona University in Flagstaff. She is a member of the Phi Kappa Phi Honors Society and made the National Dean s List. Chris is clinically certified by ASHA and a member of the American Academy of Audiology. She is intrigued by new, advanced hearing technologies such as open-ear, open-fit digital hearing aids that help people with very specific high frequency hearing needs. Chris worked in a healthcare clinic environment in Sun City for 16 years, and before that at an Ear, Nose and Throat doctor s office. She joined Audiology and Hearing Aid Center in May of Her experience includes performing advanced diagnostic tests and programming advanced hearing aid technologies in the treatment of auditory disorders and hearing loss. Chris manages the Balance and Dizziness Clinic at the Audiology and Hearing Aid Center. Kimberly Gates, Au.D., FAAA, Doctor of Audiology, has been practicing Audiology since In 2005, she received her Doctor of Audiology from the Arizona School of Health Sciences. She received her Bachelor s degree in Psychology from the University of New Orleans and earned her Master s in Audiology from Louisiana State University Medical Center. Her clinical training includes hearing assessment and rehabilitation working in private practice throughout her career. Kim s interest in technology was enhanced by her work as an electrician in the Louisiana Air National Guard for six years. Now as an audiologist, she is able to utilize her psychology background to identify the special needs of patients and her technical skills to enhance their lives through hearing aid technology. Additionally, her background includes an internship at Chinchuba Children s Institute for the Deaf and New Orleans Speech and Hearing Center. She is a member of the American Speech-Language-Hearing Association and American Academy of Audiology. Kim is originally from America s Mardi Gras city, New Orleans. Either Chris or Kimberly will be the audiologist that you will see when you come in for your appointment.

4 Patient Information Form Patient s Name: Sex: M F Birthdate: Address: Apt# City: State: Zip: Home Phone: Work Phone: Cell Phone: Soc. Sec #: Martial Status: M S W D Spouse Name: Address: Insurance Company: Occupation: (past/present) Primary Care Physician: Employer: How were you referred to us? If Doctor or Friend, please write down their name so we may thank them! Responsible Party/Insurance Subscriber: Name: Relationship to Patient: DOB: Address: Apt# City: State: Zip: Home Phone: Work Phone: Cell Phone: Attention Medicare Beneficiaries: Medicare will only pay for services that it determines to be reasonable and necessary under Section (A)(1) of Medicare Law. If Medicare determines that a particular service, although it would otherwise be covered, is not reasonable and necessary under Medicare program standards, Medicare will deny payment for that service. Please note that Medicare is likely to deny payment for Hearing Aids and Hearing Exams for the following reasons: Physician services excluded from Medicare Part B Coverage including Hearing aids, hearing aid examinations or routine audiologic examinations. By signing this document, you (the patient or responsible party) agree to be fully and personally responsible for any payment denied by Medicare. Your signature also indicates that you have read the information on this sheet, and all information you have provided is free from errors. This signature also allows our office to release your medical records to insurance companies, physicians or other medical personnel involved with your care. It will serve as a Signature on File for any insurance claims. This signature is valid indefinitely until the patient or patient s representative revokes this arrangement. Signature Date (MM/DD/YYYY) REV 09/01/06

5 Dizziness History Questionnaire Name: Age: Date: WHEN was the first time you had dizziness? WHAT were the circumstances? WHEN was the last time you experienced dizziness? WHAT were the circumstances? Currently, my dizziness is constant. is always there, but changes in intensity. comes and goes. If it comes and goes: How long does it typically last? seconds / minutes / hours (Circle ONE) How often does it typically occur? times per: hour / day / week / month / year My dizziness mostly consists of (Check ALL that apply) spells of spinning with nausea. off-balance sensation without dizziness. a light-headed or near faint sensation. double, blurred or jumping vision. other. Please explain Between episodes I feel (Check ONE) dizzy or off balance all the time. normal. other. Please explain My episodes occur (Check ALL that apply) spontaneously. Nothing I do seems to bring them on or turn them off. only when standing or walking. in relation to any head motion. in relation to only certain head positions. Please describe When I roll over in bed (Check ONE) nothing unusual happens. the room seems to spin sometimes. the room seems to spin every time. Do your symptoms occur or worsen at any particular time of day or night? Yes No If yes, when? Is there anything that you can do to make your dizziness lessen or go away? (sit, lay down, close eyes ) Please explain: PLEASE COMPLETE THE SECOND PAGE

6 Page 2 Circle all that apply: I have hearing difficulty Right..Left..Both I have ringing or other sounds Right..Left..Both I have fullness... Right..Left..Both I have had ear surgery.right..left..both Are your symptoms ever affected or brought on by any of these? (Check ALL that apply.) Standing up Loud noises Exercise Caffeine Lying down Dim lights Smoking Alcohol Fluorescent lights Menstrual periods Walking in a dark room Blowing up balloons Rapid head movements Monosodium glutamate Cough, sneeze, strain or laugh Climbing stairs or ladders Airplane, boat or car travel Elevators and/or escalators Changes in position of head or body Walking on rough or uneven surfaces Shopping malls, narrow or wide paces Watching moving objects around you Foods (eating or not eating: salt or sugar) Depression, anxiety, nerves stress Do you have any of the following symptoms with your dizziness/balance problems? (Check ALL that apply.) loss of consciousness occasional loss of vision seizures or convulsions severe pounding headache or migraine slurring of speech palpitations of the heartbeat difficulty swallowing tingling around mouth weakness in one hand, arm or leg tendency to fall double vision loss of balance when walking spots before the eyes I have or have had (Check ALL that apply) Diabetes High blood pressure Arthritis Irregular heartbeat Stroke Migraine headaches A neck and/or back injury Allergies Please check below for any MEDICATIONS you have tried FOR DIZZINESS or are currently taking: Taken in past Taking now Helps Antivert (Meclizine) Valium (Diazepam) Dyazide water pills Please list all medications that you are currently taking. Have you ever been previously evaluated for dizziness? Thank you for taking the time to complete this questionnaire. REV 09/01/06

7 Consent for Purposes of Treatment, Payment and Healthcare Operations Audiology and Hearing Aid Center 3271 N. Civic Center Plaza, Suite 4 Scottsdale, AZ As required by the Health Insurance Portability and Accountability Act of 1996 Audiology and Hearing Aid Center may NOT use your personal health information except for the purpose of treatment, payment or health care operations. The specific uses and disclosures that we intend to make are described in our Notice of Privacy Practices. You have the right to review the Notice of Privacy Practices prior to signing this consent form. You may request restrictions on the uses and disclosures described in the Notice of Privacy Practices by describing the requested restrictions in the restrictions request section of this form. Definition Information means health information, including my demographic information, collected from me and created or received by my Health Care Provider, another health care provider, a health plan, my employer or a health care clearinghouse. This protected health information relates to my past, present or future physical or mental health and identifies me, or there is a reasonable basis to believe the information may identify me. Consent I (print patient name) consent to the use or disclosure of my protected health information by Audiology and Hearing Aid Center for the purpose of diagnosing or providing treatment to me, obtaining payment for my health care bills or to conduct health care operations of Audiology and Hearing Aid Center. I understand that diagnosis or treatment of me by the audiologist may be conditioned upon my consent as demonstrated by my signature on this document. I understand I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment or healthcare operations of the practice. Audiology and Hearing Aid Center is not required to agree to the restrictions that I request, the restriction is binding on Audiology and Hearing Aid Center and the audiologist. Revocation of Consent I have the right to revoke this consent, in writing, at any time, except to the extent that the audiologist or Audiology and Hearing Aid Center has taken action in reliance on this consent. Notice of Privacy Practices Review I understand I have a right to review Audiology and Hearing Aid Center s Notice of Privacy Practices prior to signing this document. The Audiology and Hearing Aid Center s Notice of Privacy Practices has been provided to me. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations of the Audiology and Hearing Aid Center. The Notice of Privacy Practices also describes my rights and the Audiology and Hearing Aid Center s duties with respect to my protected health information. PLEASE COMPLETE THE SECOND PAGE

8 Page 2 Audiology and Hearing Aid Center reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of privacy practices by calling the office and requesting a revised copy be sent in the mail or asking for one at the time of my next appointment. My signature below indicates I have been given an opportunity to read Audiology and Hearing Aid Center s Notice of Privacy Practices and to have any questions answered before signing. Name of Patient Signature of Patient Date Restriction Request Section You have a right to request restrictions on the uses and disclosures of your protected health information as described in the Notice of Privacy Practices. Audiology and Hearing Aid Center is not obligated to accept your proposed restrictions, but will give them fair consideration. Please describe any restriction requests that you would like to make in the section provided. I, (print name) hereby request the following restrictions on the use and disclosure of my personal health information for the purposes of treatment, payment and health care operations. This is a complete list of my restriction requests. All previously signed expressions of my wishes concerning the use and disclosure of my personal health information for the purpose of treatment, payment or health care operations are null and void. Revocation Section I,, hereby revoke this consent Date Signature of Patient REV 09/01/06

9 Patient Financial Policy for Audiology and Hearing Aid Center Patient Name: DOB: Patient agrees to pay for all portions of services due in full at the time services are provided by our office. Patient Financial Policies: You are required to present a valid insurance card at every visit and as needed throughout your care. A social security number is needed for all patients or the patient becomes self-pay. If you have cancelled, rescheduled, or no showed more than 3 consecutive appointments, we will dismiss you as a patient, as this time could have been given to another patient. Commercial Insurance Carriers: We bill most insurance carriers for you if proper paperwork is provided to us. Any outstanding balances, co-payments and deductibles are due prior to checking in for your appointments. Since your agreement with your insurance carrier is a private one, we do not routinely research why an insurance carrier has not paid or why it paid less than anticipated for care. If an insurance carrier has not paid within 60 days of billing, fees are due and payable in full by you. Medicare: Our office is a Medicare participating provider and we will bill Medicare for you. Medicare only covers a complete hearing test if referred by a physician for a medical condition. Hearing aids are not a covered benefit. If your secondary insurance does not crossover, it is the patient s responsibility for filing these claims. As a courtesy, we will mail you a claim form that you can then send to your insurance carrier. Any outstanding balances and deductibles are due prior to your appointments. Any non-covered service will be due as service is rendered. Worker s Compensation: If your visit is work related, we will need the case number and carrier name prior to your visit in order to bill the worker s compensation insurance company. Methods of Payment: Our office accepts the following payment methods: Cash, Personal Check, Credit Cards and Patient Financing options for those patients who qualify. For returned checks, we assess a $30.00 NSF charge. If not paid according to these terms, the patient understands that our office reports to an outside collection agency. In the event that your account is turned over for collections, patient agrees to pay all additional fees assessed in the collection of the debt. These fees include collection agency fees and attorney fees and you will be dismissed as a patient. The patient is ultimately responsible for all fees for services. Signature: Date: REV 09/01/06

10 How to Find Us Audiology and Hearing Aid Center 3271 N. Civic Center Plaza, Suite 4 Scottsdale, AZ From the East Side If traveling on the 101 Freeway, take the Thomas Road Exit Go west on Thomas Road At Civic Center Plaza, go north Once you reach Civic Center Plaza, go north for 1 ½ blocks and our office building is on your right We are in Suite 4 Parking and entrance is in the rear (East Side) From the South Side From Red Mountain or Superstition Freeways, go north on Scottsdale Road Then go east on Earll Drive for 2 blocks Once you reach Civic Center Plaza, go north and our office building is on your right We are in Suite 4 Parking and entrance is in the rear (East Side)