For your convenience, complete the following information, and one of our team members will follow up with you the next business day. If you provide your insurance information, we can check your benefits on your behalf before your appointment. Request an Appointment Name Email Phone Street Address City State Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code Date of Birth Would you like to discuss hearing aid devices during your appointment? Yes No Primary Insurance Company Subscriber ID # Group ID # Insurance Phone # for Eligibility / Benefits/Provider Services Policy Holder's Name Policy Holder's Date of Birth Secondary Insurance Company Secondary Insurance Subscriber ID # Secondary Insurance Phone # for Eligibility / Benefits/Provider Services Secondary Group ID # Secondary Policy Holder's Name Secondary Policy Holder's Date of Birth Upload Picture of Insurance Card(s) Preferred Office Location Cleveland, TN Athens, TN Preferred Day of the Week for your Appointment SELECT DAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY Preferred Time of Day Morning Afternoon Either Other Comments: SUBMIT