To begin your insurance verification process with Oticon Medical, please complete the form below and provide images of the front and back of your insurance card(s) via email to InsuranceServices@oticonmedical.com or fax them to 888-683-8736. Once received, we will review your benefits and inform you of your coverage options. Please note we cannot begin working on a request until this has been received.
Once you have completed the form below and provided copies of your insurance card(s), please note that we will also need the following from your hearing healthcare provider:
- Provider Intake Form
- Letter of Medical Necessity signed by your physician
- Most recent clinical notes and audiogram (must be from the past 12 months)
Note: Form fields with a red * are required. For our Glossary of Insurance Terms, click here.
Insurance Patient Acknowledgements & Waivers
To be completed by Ponto user, guardian, or authorized representative
I understand that I may view Oticon Medical marketing materials and information on Oticon Medical’s scope of services at the Oticon Medical website: https://www.oticonmedical.com/us.
I understand that Oticon Medical is a supplier of medical devices and I should rely on my own health care provider for medical advice, diagnosis, and expected outcome of the use of an Oticon Medical implantable device.
Assignment of Benefits
I hereby assign my insurance benefits to be paid directly to Oticon Medical. I understand and agree that a copy of this authorization and/or assignment of benefits, when signed by me, my authorized representative, or a legal guardian, may be sent to my insurance company for benefit determination.
I authorize and assign Oticon Medical the right to pursue and receive payment from my insurance carrier, as well as the right to pursue all administrative appeals and litigation, and any other causes of action as necessary to pursue payment related to my receipt of sound processor implants and/or related services from Oticon Medical.
Financial Liability
I understand that if my health insurance does not provide coverage for, or denies payment for, any of the services provided to me, Oticon Medical may bill me for those services, unless doing so would be prohibited by state or federal law, and I assume responsibility for payment of the billed amount in full. If patient is in possession of a loaner processor that was provided by Oticon Medical, they will be billed for any remaining balance if this device is not returned within the 90-day return period. I also hereby transfer and assign to Oticon the proceeds of any claim, proceeding, suit and/or action for damages payable to me, my representative or my estate, up to the cost of those services provided to me by Oticon Medical not covered by my health insurance.
I am responsible to notify Oticon Medical of any changes in my address and in my health care coverage, and failure to do so may result in delays in processing my order or inability to process my order;
In some cases, exact insurance benefits cannot be determined until the insurance company receives the claim and this may delay the processing of my order with Oticon Medical;
Since I am assigning to Oticon Medical my right to receive payment directly from my insurance company or from Medicare or Medicaid, if I receive payment directly, I agree to reimburse fully Oticon Medical upon request for the cost of my order(s) and I understand that Oticon Medical has the right to recover its cost of collection from me if I fail to reimburse Oticon Medical properly and timely, in this circumstance;
I will promptly (within 5 business days) forward all insurance correspondence (such as explanation of benefits and other similar forms or communication) related to my order(s) to Oticon Medical’ address below;
I certify that the financial and insurance information I supplied is correct and that I have been informed of my financial obligations.
Notice of Privacy Practices
Our Responsibilities
We are required by law to maintain the privacy and security of your protected health information.
We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
We must follow the duties and privacy practices described in this notice and give you a copy of it.
We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.
Other Instructions for Notice
Effective Date of this Notice: February 01, 2017
For questions regarding the insurance process, please contact our dedicated Insurance Support Services team at the email above anytime or call 888-400-9761 (Mon-Fri, 8am-5pm ET).