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Ear Exam

Provider Claim Submission

For providers only
Submit a claim for reimbursement

Please fill in the following information for fitting or follow up reimbursement

Patient First and Last name

Patient Insurance ID#

Patient Insurance Company

Provider email

Clinic Name and/or Provider Name

Fitting Date (if applicable)

Follow-up Date (if applicable)

Additional information or questions

Thanks for submitting!

Together with

Contact us

info@bestvaluehearing.org

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