ADA Practice Resource Catalog

ADA is pleased to announce the introduction of our Practice Resource Catalog.  This catalog will offer a comprehensive library of off-the-shelf forms, office forms, documents, and guidance materials. These materials will assist audiologists and their staffs with practice operations, compliance, and patient management.

NOTE: ADA cannot issue refunds on these products after purchase. Please contact info@audiologist.org with any questions before purchasing.

Documents contained in the Practice Resource Catalog are the intellectual property of the Academy of Doctors of Audiology. Any replication or dissemination without the express consent of ADA is strictly prohibited.

Hearing Aid Resources


Hearing Aid Loaner Agreement
This is a patient/practice document. This document allows you to hold the patient responsible for any loaner or demo aids in their possession. This form is provided in a Word format.

ADA Member Price: $49.00
Non-Member Price: $99.00




    Hearing Aid Upgrade Notice
This is a patient/practice document. This document allows you to notify the patient, in writing, of their financial responsibilities when the third-party payer contractually allows hearing aid upgrades. Many BlueCross/Blue Shield plans require the use of an upgrade waiver when a patient selects upgraded hearing aids. This form is provided in a Word format.

ADA Member Price: $99.00
Non-Member Price: $199.00




Notice of Non-Coverage Form
This is a patient/practice document. This document allows you to notify the patient, in writing, of their financial responsibilities when the third-party payer does not cover a specific item or service. Many third-party payer agreements require the use of a written notice of non-coverage when a patient receives an item or service that is non-covered. This form is provided in a Word format.

ADA Member Price: $99.00
Non-Member Price: $199.00




    Hearing Aid Insurance Waiver
This is a patient/practice document. This document allows a patient to waive their insurance coverage for hearing aids. This form is provided in a Word format.

ADA Member Price: $99.00
Non-Member Price: $199.00




Hearing Aid Orientation and Verification Checklist
This is a patient/practice document. This form documents a patient understanding and acceptance of the hearing aid fitting and orientation process. This form is provided in a Word format.

ADA Member Price: $49.00
Non-Member Price: $99.00




    Price Quote Form
This is a patient/practice document. This document allows you to quote the patient the price of the hearing aid(s), earmold(s), accessories, and estimated insurance coverage. This form will also describe basic dispensing policies. This form has been created to conform to a bundled delivery model. This form is provided in a Word format.

ADA Member Price: $49.00
Non-Member Price: $99.00




Insurance Verification Form
This is an operations document. This internal office document follows the flow of an insurance verification call and includes all of the questions necessary to effectively and appropriately verify insurance coverage and benefits for hearing aids. This form is provided in a Word format.

ADA Member Price: $49.00
Non-Member Price: $99.00




    Hearing Aid Bill of Sale/Purchase Agreement (specific to each of the 50 states)
This is a patient/practice document. This document, specifically created to meet the legal requirements of each state, includes information such as make and model of aid, serial numbers, condition of aid, warranties, terms of purchase, patient and audiologist signature, dates, and costs. This form has been created to conform to a bundled delivery model. This form is provided in a Word format, and will be delivered in 5-10 business days upon purchase.

ADA Member Price: $249.00
Non-Member Price: $500.00




Hearing Aid Package
Includes Insurance Verification form, Hearing Aid Price Quote form, Bill of Sale, Hearing Aid Orientation Checklist, Upgrade Notice, Notice of Non-Coverage, Insurance Waiver, and Loaner Agreement
ADA Member Price: $499.00
Non-Member Price: $999.00




   

HIPAA Resources


HIPAA Security Policy Template
This template provides practices with a comprehensive outline of the administrative, technical and physical safeguards required under the HIPAA Security Rule, effective April 2005.

ADA Member Price: $350.00
Non-Member Price: $600.00




    HIPAA Tool-Kit
The Academy of Doctors of Audiology (ADA) has commissioned our legal counsel, Robert Gippin, Esq and the law firm of Roderick, Linton and Belfance LLP to create HIPAA Compliance documents and forms that can be purchased by our members. The package includes:
  • Notice of Privacy Practices
  • Acknowledgement of Notice of Privacy Practices (comprehensive and truncated)
  • Business Associate Agreement
  • Use and Disclosure form
  • Marketing Acknowledgement
ADA Member Price: $199.00
Non-Member Price: $499.00




HIPAA Bundle
Includes the HIPAA Security Policy Template and HIPAA Tool-Kit (Notice of Privacy Practices with 2013 Omnibus required modifications, Business Associate Agreement with 2013 Omnibus required modifications, Acknowledgement of the Notice of Privacy Practices, Use and Disclosure form and Comprehensive Marketing Authorization with 2013 Omnibus required language). The HIPAA ToolKit is available in a .pdf format and the HIPAA Security Template is available in both a .pdf and Word formats.

ADA Member Price: $549.00
Non-Member Price: $1099.00




   

Practice Resources


2016/2017 Superbill with ICD-10
This form has been updated with the 2016/2017 CPT codes, 2016/2017 ICD 10 Coding changes, and the 2017 PQRS updates. The CPT and ICD 10 codes contained on this form are effective October 1, 2016. PQRS is scheduled for retirement on December 31, 2016, although this is not official until November, 2016. PQRS codes must be successfully reported until December 31, 2016 to avoid any penalties. Note: There are no PQRS codes at this time for 2017.

ADA Member Price: $249.00
Non-Member Price: $500.00




    Patient Registration Form
This is a patient intake/registration document. This two-page document includes the most needed information including: patient demographics, marketing tracking, requested disclosures, problem pertinent case history (including warning signs of ear disease and basic audiologic and hearing aid information), current medications, financial policy acknowledgement, HIPAA marketing authorization and HIPAA Notice of Privacy Practices acknowledgement. This form is in a Word format.

ADA Member Price: $99.00
Non-Member Price: $199.00




Adult Case History
This is a comprehensive adult case history form. This form includes: problem pertinent case history (including warning signs of ear disease and basic audiologic and hearing aid information), current medications, and a comprehensive review of systems (which can be valuable when utilizing evaluation and management codes). This form is in a Word format.

ADA Member Price: $49.00
Non-Member Price: $99.00




    Office and Financial Policy Document
This is a template of a patient office and financial policy. It includes: insurance policies, payment policies, forms of payment accepted, finance options, no show fees, and bounced check fees. This form is in a Word format.

ADA Member Price: $99.00
Non-Member Price: $199.00




Employee Manual
Includes sample policies on Attendance, Bereavement Leave, Code of Conduct, Confidentiality, Continuing Education, Corrective Action, Dress Code, Grievances, Safety, and more.
ADA Member Price: $499.00
Non-Member Price: $999.00




    Practice Management Package
Includes Registration Form, Case History, Office & Financial Policy, and the Superbill
ADA Member Price: $349.00
Non-Member Price: $700.00




   


ADA Member Documents

ADA Members: Login and click here to download the documents below.
  • Medical Clearance [MS Word format]
  • Medical Waiver [MS Word format]
  • Customized Advanced Beneficiary Notice (ABN)- Required [MS Word format]
  • Customized Advanced Beneficiary Notice (ABN)- Voluntary [PDF format]
  • ICD10 Coding Chart [PDF format]


Many of the forms and documents that are available for purchase through ADA have been created in either Microsoft Word or Microsoft Excel format. These formats will allow for customization and editing by you and your practice.

Some forms and documents, including but not limited to, superbills, hearing aid purchase receipts, and HIPAA materials, may require modification at a later date due to compliance and regulatory changes. These changes will be the responsibility of the purchaser and not the responsibility of ADA.

Prior to purchasing a form or document from ADA, please note that any modifications, adjustments, or changes to a specific form or document are the responsibility of the purchaser. ADA, its staff and consultants will not modify or customize any of these forms and documents once purchased.

All materials, content and forms contained on this website are the intellectual property of ADA and may not be copied, reproduced, or distributed beyond the use of your practice without ADA's express written permission.

ADA does not warrant, either expressly or implied, the accuracy, timeliness, or appropriateness of the information contained in the documents or on its website. ADA disclaims any responsibility for content errors, omissions, or infringing material and disclaims any responsibility associated with relying on the information provided on this website.