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Al.com Check List Reimbursement Support Services Intake Form (Pages 1-3) Notice of Privacy Practices (Page 4) Patient Acknowledgements and Waivers (Page 5) Copy of the Patience s Insurance Card(s) (clear/enlarged copies of the front & back) Documentation/Letter of Medical Necessity, Audiogram(s) and Other Clinical Notes/Rationale *For your convenience, you may review the following documents on our website at: https://www.oticonmedical.com/us/downloads. Notice of Privacy Practices, Oticon Medic.

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