Patient Forms, Portal, and
Bill Pay (NY Only)

Intake Forms

We’re pleased that you have chosen the Center for Hearing and Communication for your hearing healthcare needs. When you come for your appointment, please bring all the information your clinician will need to provide you with the highest quality care.

Intake Forms (NY Only)

If you will be receiving audiology services with us for the first time, please download and print out the appropriate intake form. Fill in the requested information and bring the completed form with you when you come for your appointment.

Download the Adult Intake Form

Download the Child Intake Form

Medical Clearance Form

If you are required to obtain medical clearance for a hearing aid, please have an ENT fill out the following form and bring it with you when you see your CHC audiologist for a hearing aid evaluation.

Medical Clearance Form

Other information that may be needed:

Copies of prior hearing evaluations (if done at another facility)
A referral from your doctor if you have Medicare
Prior speech and language evaluation results (if available)
Psychological evaluation results (if available)
IEP or Individualized Education Program (if your child has one)
Your child’s immunization documents

Health Insurance Plans and Programs

New York Office

If you are uncertain about which information to bring, please call (917) 305-7700 and enter “zero” to speak with the receptionist.
We accept most insurances, so please call/ email to find out.

Florida Office