Patient Request - 10 pages or less - $ 5.00 minimum per request
Other Source Request - 10 pages or less - $10.00 minimum per request

Plus
$ .75 per page - 11 to 25 pages
$ .50 per page - 26 to 100 pages
$ .25 per page - greater than 100 pages

**** Signed Records Release Required for most requests ****

Important Note

• Patients may obtain a copy of their Audiogram or results of Diagnostic tests
  at the time of the office visit at NO CHARGE.

FMLA/DISABILITY/INSURANCE FORMS, EMPLOYER REQUIRED FORMS

(Payment required prior to completion of forms)

1 page (single side) form - $10.00
2-5 page forms - $25.00
6 pages or more - $40.00