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Intake Page 1
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Intake Page 2
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Intake Page 3
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Intake Page 4
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Subjective
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Subjective Complaint
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Onset
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Impact on Daily Life- Functional Impaiment
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Occupational History
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Occupational Noise Level
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Other
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Other Relevant History
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Other
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Objective
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Otoscopic Findings
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Other
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Audiometry Results
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Speech Audiometry
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Right Ear- Speech recognition threshold (SRT)
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Left Ear- Speech recognition threshold (SRT)
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Assessment:
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Assessment (Medical Necessity Considerations)
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Other
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Assesment: (Functional Impairment Justifying Medical Necessity)
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Other
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ICD-10 Codes
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Other
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Plan:
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Plan: Treatment recommendations (Supporting Medical Necessity)
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Other
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Rationale
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Other
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CPT Codes
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Other
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HCPCS Codes
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Other
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Follow-Up
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Additional Information (Documented Functional Impairment)
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Expected Benefit with Hearing Aid Use
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Other
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Patient is Motivated to Use Hearing Aids
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Other
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