Patient Verification Request Form

Click here to review and download .pdfs of our patient acknowledgements and waivers, including our Notice of Privacy Practices.

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 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).

Patient Information
*
*
*
*
*
*
*
*
*
Unilateral (one ear) or Bilateral (both ears)
Insurance Information
*
*
*
*
*
*
Type of Insurance Plan
Secondary Insurance Information
Type of Insurance Plan
Clinic Information
*
*
*


By checking this box, I signify that this will serve as my electronic signature on these forms. This also serves as my acknowledgement/receipt of the Billing Service Recipient Bill of Rights and Responsibilities, DME POS Supplier Standards, release of information, Notice of Privacy Practices and a Billing Service description. I have received the product manual/instructions and warranty information, if applicable.

*