Patient Registration

If you have an upcoming appointment and need to register the patient with Start Hearing, please fill out this form. Your registration will be assigned to a Caring Center Advisor, they’ll reach out with any questions and will send you an appointment confirmation. If you have any questions or would rather do the registration via phone, please call Start Hearing Customer Service: 888-304-8539.

Patient Registration Form Submission

Patient Information

First Name

Phone Number

Last Name

Street 1

Plan Name

Street 2

Member ID

City

Date of Birth

State

Gender

Zip Code

Test Appointment Date

Test Apointment Time

Provider Information

Location Name

Location TIN

Provider First Name

Location NPI

Provider Last Name

Location Phone

Location Street1

Location Email

Location Street2

Provider Type

Location City

Provider NPI

Location State

Provider Email

Location Zip Code

Name

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