Spirit River Audiology

You have the right to:

• see and get a copy of your health information,
• ask for changes to your health information if you see a mistake or missing information,
• know how your health information is used or shared with others,
• ask us to restrict how your health information is used or shared with others,
• ask us to reach you in a certain way or place,
• have a copy of the notice, and
• file a complaint if you feel your rights have been violated at Spirit River Audiology, 110 1st Avenue East, Suite 2, Cambridge, MN 55008 Attention: Privacy Office or (763) 742-4844.

I ask that insurance payments be made to Spirit River Audiology and to those providing care. Spirit River Audiology may share health and account records with payers as needed for billing, payment and claims. I will accept financial responsibility for all charges for services rendered to me by Spirit River Audiology, LLC and/or which are not covered by my insurance plan. Payment in full is due on the date of service.

It will also apply if treatment is started with Spirit River Audiology. I agree to care that my audiologist believes is needed. I will have a chance to discuss this care with my audiologist, who cannot promise specific results. To provide this care Spirit River Audiology may collect information about my health.