Microsoft word - 4 vng evaluation.docx

Patient Instructions for VNG Testing
The videonystagmography (VNG) test is designed to give your physician information regarding the source of your imbalance, dizziness, and/or vertigo. The VNG test has 3 main parts: (1) following a light with your eyes, (2) sitting and laying with your head and body in different positions, and (3) irrigating each ear with warm and cool air. Eye movements and the inner ear are neurally connected and allow for proper balance. Your audiologist can determine the function of the inner ear by observing and recording your eye movements through the use of goggles that record and measure very fine eye Portions of the test may induce the sensation of vertigo (spinning), but this effect is brief and temporary. There is no pain or needle sticks from this test. We recommend that you have someone drive you to and from your appointment in the event you experience vertigo from this assessment. PLEASE ALLOW AT LEAST 1 HOUR FOR THIS TEST.
However, if you are also having other evaluations completed (e.g., Hearing Assessment, EcochG, ABR, and VEMP), more time may be necessary. If you have questions about your appointment beginning and ending times, please contact our office for assistance. PRE-TEST INSTRUCTIONS
Following these instructions is imperative to an accurate and reliable test result. Failure to comply with these instructions may result in rescheduling your appointment. 1. Discontinue ALL medications 48 HOURS prior to your testing that you have taken
LESS THAN 6 MONTHS EXCEPT those taken for your heart, blood pressure,
diabetes, or seizures AFTER obtaining approval from your prescribing physician(s).
2. NO beverages containing alcohol for 48 HOURS prior to testing.
3. Do NOT consume a level of caffeine that is abnormal for you 1 DAY prior to testing.
4. NO tobacco use of ANY form on the day of testing.
5. Do NOT eat 2 HOURS prior to testing. If you must eat for health reasons, please eat
6. Your face should be thoroughly washed and clean of make-up of ANY kind
(including lotions/creams, mascara, eye liner, eye shadow, foundation, powder, etc.)
These are examples of medications you should not take 48 hours prior to testing IF you
started taking them within the past 6 months:
a. Acetaminophen (Tylenol, Tylenol PM, etc.) b. Ibuprofen (Advil, Motrin, Excedrin, Midol, etc.) c. Aspirin d. Naproxyn (Aleve) e. Codeine f. Darvocet g. Migraine Medications 2. All anxiety or depression medications, IF allowed by your physician, including: a. Valium or Diazepam b. Ativan or Lorazepam c. Pamelor or Nortriptyline d. Compazine e. Xanax f. Prozac g. Zoloft 3. All anti-dizzy medications, including: a. Antivert or Meclizine b. Valium c. Phenergan d. Dramamine e. Scopolamine (Transderm patch) 4. All diuretics or water pills, including: a. Dyazide b. Maxide c. Neptazane d. Lasix 6. All sinus and allergy medications, including: a. Antihistamines (Benadryl) b. Decongestants (Sudafed) Hearing and Balance Evaluation Fee Policy
The following services are the typical billing codes for hearing, electrocochleography (EcochG), and videonystagmography (VNG) studies. Once the audiologist obtains the case history, appropriate tests will be administered. PLEASE ALLOW AT LEAST 3 HOURS FOR THIS
Office Service
Comprehensive Audiometry Threshold Evaluation and Speech Recognition Tympanometry and Acoustic Reflex Thresholds Vestibular Evaluation: Part 1 of Videonystagmography (VNG) Bithermal Calorics: Part 2 of Videonystagmography (VNG) * If the patient recently underwent audiometric testing at an otolaryngologist’s (ENT) office, these tests may not need to be administered. Bridgewater will file a claim with your insurance company for all testing; however, you may be responsible for the remaining balance. It is the patient’s responsibility to contact his/her insurance company to
determine if the services to be conducted are covered.
For CIGNA insurance, Bridgewater is credentialed as an “Ancillary Provider” and therefore covered under the corporation Bridgewater Speech and Hearing. Registration and Consent
Social Security Number: __________ - ________ - __________
Last Name: ____________________________ First Name: ___________________ MI: ____
Preferred Name: _______________________ Date of Birth: _________________ Age: _____
Male/Female Home Phone: (______)_______-_________Cell Phone: (______)_______-_______
Work Phone: (______)_______-________ Email Address: ________________________________
Street Address: ________________________________________________________________
City: ______________________ County: _______________ State:_________ Zip: ________

Who may we contact in case of an emergency?______________ Phone: (_______)_______-________
Who may we thank for referring you to Bridgewater? _______________________________
Who is financially responsible for the bill? _________________ Phone: (_______)_______-________
I authorize Bridgewater Balance and Hearing, Inc. to release information requested with regard to
processing my claims.
Yes or No
I authorize Bridgewater to disclose any or all parts of my protected health information to the
individuals listed below. I acknowledge this with my signature within the Patient’s Benefit
Assignment, Privacy Notice, and Contact Authorization below:

Contact Preference: ____Confidential ____ Do NOT call ____Okay to Leave Message ____E-Mail
The evaluation and treatment procedures by Bridgewater clinicians are professionally and ethically
acceptable and offer no probable physical or psychological risk. Although procedures are expected to be
of benefit, I understand that no guarantee of success can be expressed or implied. I agree to the scheduled
procedures and understand I may discontinue the evaluation or treatment at any time.
I understand and agree that regardless of my insurance status, I am ultimately responsible for the balance
on my account for any professional services rendered. All registration information is correct to the best of
my knowledge. I will notify Bridgewater Balance and Hearing, Inc. should the above information
Privacy Notice: I confirm that I have been given a copy of the Bridgewater Balance and Hearing’s
Notice of Privacy Policies and understand my privacy rights.

Signature: _________________________________________ Date: _____________________
Guardian Signature (if Patient is a minor): ________________________________________

Financial Responsibility for the Cost of Services
Insured Name (Print Clearly): ____________________________ Insured’s Date of Birth: _________
Please List Primary and Secondary Insurances Below:
___________________________________ _________________________________ ______________
Primary Insurance Company Name

Member ID Number
Date of Birth

___________________________________ _________________________________ ______________
Secondary Insurance Company Name

Member ID Number
Date of Birth

Name of Primary Care Physician: _______________________________________________________
Services Requested: Auditory, Vestibular, and/or Diagnostic Evaluations

I know that commercial and state sponsored insurances pay for healthcare. I know when I get health care, my doctor sends the charges to my insurance company for payment. I know I must show my ID card to all doctors and hospitals before I get health care. I know a copayment is when I have to pay part of the bill each time I receive certain health care services. I know that it is my responsibility to get all insurance authorizations in advance.
Please initial each statement below that applies to you:
________ I have Medicare, Medicaid, or TENNCARE. I asked for one or more of the health care

service(s) listed below. I understand my insurance may not pay for it.
*A physician referral is REQUIRED to bill Medicare.

________ I have private commercial insurance. I asked for one or more of the health service(s)

listed below. I understand my insurance may not pay for it.
My doctor has told me how much of the health care service(s), listed below, I may have to pay. Balances listed below may be added to any applicable deductibles. I must pay my balance in a timely manner
in order for the discounted amount to remain in force.
The patient is also responsible for any balance listed as patient responsibility.
Cost of Service
Patient Balance is NOT to Exceed:
** If you request that Bridgewater Balance and Hearing bills your insurance company for hearing instruments, the PATIENT is responsible for all hearing aid balances over the actual insurance reimbursement amount of the devices. ** If you request that Bridgewater Balance and Hearing files your claim, provider write-off and discount amounts are NOT applicable on hearing instrument purchases. ** Patients that choose to purchase hearing instruments that EXCEED the amount of insurance coverage on their plan do so with the understanding that they agree to pay ALL BALANCES over the actual insurance reimbursement amount. By signing this paper, I agree to pay for the services listed above in a timely manner.

___________________________________________ _______________________________________
Printed Name of the Responsible Person

Signature of Member or Responsible Person
Record Release
I authorize Bridgewater Balance and Hearing to issue
my hearing healthcare information to:

___ Physician(s): ______________________________________________________________
___ Insurance Company: _______________________________________________________
___ Other(s): __________________________________________________________________
Patient Signature: ________________________________________ Date: ________________

Release of Records from Another Healthcare Provider
I authorize a release of my hearing and balance records to
Bridgewater Balance and Hearing from:

Patient Signature: ________________________________________ Date: ________________
Witness: ________________________________________________ Date: ________________
Please Fax Records to:
____ Knoxville Office at (865) 769-0281
____ Sevierville Office at (865) 429-0719

Please Provide a List of Your Current Medications
Confidential Patient History
Patient’s Name: _______________________________________________ Date: ___________________

Have you seen a doctor in the past 6 months? If yes, who have you seen? ___________________________________________ Have you seen a doctor specializing in diseases of the ear (e.g., ENT)? If yes, who have you seen? _____________________ When?_______________ Have you ever had your hearing tested? If yes, give a date: _____________________ by whom? ___________________ Do you have a heart condition? If yes, please explain: _______________________________________________ Do you have a pacemaker of defibrillator? Do you have any significant medical conditions (e.g., high blood pressure)? If yes, explain: _____________________________________________________ Do you take medicine every day? If yes, explain for what conditions: _____________________________________ Have you ever had any type of ear surgery or trauma? If yes, explain: _____________________________________________________ Have you had head trauma? If yes, explain: _____________________________________________________ Do you experience significant sinus and/or allergy issues?

Deformity of the ear If yes, which ear(s)? BOTH RIGHT LEFT Tinnitus (ringing or buzzing in the ear) If yes, which ear(s)? BOTH RIGHT LEFT Fullness or stuffiness of the ear If yes, which ear(s)? BOTH RIGHT LEFT Pain in your ear If yes, which ear(s)? BOTH RIGHT LEFT Drainage from the ear (aside from ear wax) If yes, which ear(s)? BOTH RIGHT LEFT Sudden or rapid change in your hearing sensitivity Excessive ear wax requiring removal by a physician

Are you concerned that you have hearing loss? If yes, for which ear(s): BOTH RIGHT LEFT If yes, how long have you had difficulty hearing? ____________________________ If yes, which is your poorer ear? SAME RIGHT LEFT Does anyone in your family have a hearing problem? If yes, what relationship? _______________________________________________ Do you or have you ever worn a hearing aid? If yes, how do you think you may be helped? ________________________________ Do you have difficulty understanding conversations in quiet? Do you struggle to understand speech in the presence of background noise? Do you have difficulty hearing on the telephone? Have you been exposed to loud noises (e.g., gunfire, explosions, power tools, factory noise, machinery, lawn equipment, loud music, etc.)? If yes, did you wear hearing protection?
Signature or Guardian Signature: ___________________________________ Date: __________________

Dizziness Questionnaire
Patient’s Name: ______________________________________ Date: ___________________
Please read through the entire questionnaire FIRST. Then, circle “Yes” or “No” to describe your feelings most accurately. Answer all questions completely – fill in ALL blanks. Yes Do you experience chronic and/or acute dizziness? If not, do not complete the following questions. If yes, proceed to the following questions. My dizziness comes in attacks. If in attacks, how often do they occur? __________________________________ How long does your attack of dizziness last? _____________________________ When did the dizziness first occur? _____________________________________ Are you completely free of dizziness/instability in between attacks? YES NO Does a change in body position initiate your attacks of dizziness? YES NO If yes, explain: _______________________________________________ Do you have a warning that the dizziness is about to start? YES NO If yes, explain: _______________________________________________ Do the attacks occur at a particular time of day (e.g., day or night)? YES NO If yes, explain: ________________________________________________ Sensation that you are spinning and your environment is stationary? Lightheadedness or swimming sensation in your head? Blacking, loss of consciousness, and/or confusion? Tendency to fall? If yes, to what direction(s)? RIGHT LEFT FORWARD BACKWARD Loss of balance when walking? If yes, to which direction do you veer? RIGHT LEFT Do you know any possible cause of your dizziness? If yes, explain: _____________________________________________________ Do you know of anything that will stop your dizziness or make it better? If yes, explain: _____________________________________________________ Do you know of anything that will make your dizziness worse? If yes, explain: _____________________________________________________ Exposure to irritating fumes, paints, etc. at the onset of your dizziness? Do you experience any tinnitus (ringing or buzzing in your ear) or change in your tinnitus when you are dizzy? If yes, explain: _____________________________________________________ Have you experienced any of the following symptoms? If you circle “Yes,” please indicate whether you experience that symptom constantly or in episodes with your dizziness. Yes Do you have a follow-up appointment with your physician or otolaryngologist (ENT) already scheduled? If yes, please indicate the date and time: ____________________________
Additional Comments: ___________________________________________________________



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Microsoft word - vip 10 draft.docx

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