First Name
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Last Name
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Date of Birth
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Phone
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Email
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Address
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Postal code
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Insurance
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Insurance
Anthem
Anthem Ky Medicaid
Anthem Medicare Replacement
Allsavers
Aetna
BCBS
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Caresource Medicaid
First Health
GEHA
Humana
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Wellcare Medicaid
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Diagnosis
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Diagnosis
Ear Wax
Ringin In Ears (Tinnitus)
Dizziness/Vertigo
Ear Infection
Pain/Fullness in Ears
Ear Drainage
Hearing Loss
Evaluation for Tubes
TM Perforation
Meniere's
Sinusitis
Rhinitis
Polyps/Cysts/Masses (Inside Sinuses)
Nasal Allergies
Nasal Perforations
CSF Leak
Nosebleeds
Trouble with Smell or Taste
Deviate Septum
Tonsils/Adenoids
Tonsil Stones
Snoring
Sore Throat
Hoarseness
Trouble Swallowing
Cough
Thyroid Nodules/Goiters/ Other Thyroid Issues
Obstructive Sleep Apnea
Problem Not Listed
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Doctor
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Doctor
ANY DOCTOR
Dr. Jeffrey Nau
Dr. Michael Brown
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Referring Provider
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