Mid America Audiology Group (main facility)
1417 Washington Ave., Suite 2
Alton, IL 62002
Phone: (618) 462-7900
Fax:
(314) 462-0179
www.midamericaaudiologygroup.com
Appointment at:
Ginger Creek office (Hwy 157 & Ginger Creek)
#9 Glen-Ed Professional Office Park
Glen Carbon, IL 62034
1. Start out going east on University Park Dr toward S State Route 157/IL-157. 0.3 mi
2. Turn right onto S State Route 157/IL-157.
0.8 mi
3. Turn left onto Ginger Creek Dr.
0.04 mi
4. Take the 1st left onto Glen Ed Professional Park.
0.09 mi
5. 9 GLEN ED PROFESSIONAL PARK is on the right.
Supervisor/P-Card Signer should complete shaded blanks below.
Appt. Date: __________________________
Appt. time: ______________
SIUE Employee: ______________________________ Employee ID#: _____________________
Reason: ____ Baseline
____ Recent STS
_X_ Missed Appointment
Services to receive: Audiological Exam, History, & Consult
X Normal or Mild Loss , charge of $______-air-conduction testing ONLY, for the following
frequencies: 500 Hz, 1,000 Hz, 2,000 Hz, 3,000 Hz, 4,000 Hz, 6,000 Hz, and 8,000 Hz
____ Profound Hearing Loss – charge of $______- do air and bone conduction testing, for the
following frequencies, 500 Hz, 1,000 Hz, 2,000 Hz, 3,000 Hz, 4,000 Hz, 6,000 Hz, and 8,000 Hz
P-Card Number: _____________________________
Expiration Date: ______________
Authorized Signature: ________________________
Date Signed: _________________
Email of Signer: ____________________
Phone of Authorized Signer: _________________
Dept. Billing & Mailing Address : ______________________________________________________
____________________________________________________________________________________
Results and Interpretations to be sent to Loren Paul, Safety Officer III, lpaul@siue.edu
Southern Illinois University – Edwardsville
(618) 650-3592
Emergency Management & Safety
Fax: (618) 650-2196
Campus Box 1657, Edwardsville, IL 62025