COVID-19 Location Closures

To ensure our health plan members are referred to open locations that can serve patients, it is important for us to understand how COVID-19 may be impacting your business.

Should the status of your location(s) change over the coming days or weeks, please inform us of that change by completing this form again or calling us at 800-920-4327.

Question Title

* 1. Please list any location that will close temporarily due to COVID-19 concerns.

Amplifon location number

Clinic name

Street address 1

Street address 2

City

State

Zip

Question Title

* 2. If you are closing temporarily, please indicate what date this will take effect.

Date

Date

Question Title

* 3. If you are closing temporarily, please indicate what date you currently anticipate you may re-open.

Date

Date