Our goal is to provide the best ENT care in the Hampton Roads region for people of all ages.

ENT LTD. PATIENT PORTAL

Before Your Visit

Your First Visit   •   Your Child’s First Visit   •   Request for Release of Information   •   No Show Policy   •   Financial Policies   •   Patients w/ Health Insurance   •   For Self-Pay Patients   •   Participating Insurances   •   Hospital Affliates   •   Hospital Affliates

Your First Visit:

Take a moment and look over the forms we require for your visit.
First Visit, and yearly after that, you will complete the appropriate Administrative Data Sheet below.

In order to download and view the following files you will need the free ADOBE ACROBAT READER. If you need to download the reader link below and follow the instructions.

ENT LTD. Adult- Administrative Data Sheet Adult  
ENT LTD. Child- Administrative Data Sheet Dependent
ENT LTD. HIPAA Written Acknowledgement Form
ENT LTD. Patient History Form (First time only)

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Your Child’s First Visit:

It is highly recommended that you bring your child in on their first visit to make sure the correct paper work has been completed. On subsequent visits, If you plan to have someone else bring your child, you will need to fill out the following form. You can save time by downloading the appropriate form before your visit and completing it before you arrive.

ENT LTD. Authorization to Give Consent for Medical Treatment

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HIPAA:

We are also required by law to provide you with our "Notice of Privacy Practices" (NPP). This also available at the offices.

This is a requirement as spelled out in the Health Insurance Portability and Accountability Act (HIPAA), 45 CTR Parts 160 and 164 (the "Privacy Regulation"). Health Care Providers at Ear, Nose and Throat, Ltd. have adopted privacy policies regarding usage of patients' right to privacy. Please click on the following link to review the NPP

Once you have reviewed it you can download the "HIPAA Notice of Privacy Practices Written Acknowledgement Form" and fill in the appropriate areas, sign it and bring that along with you.

ENT LTD. HIPAA Written Acknowledgement Form

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Request for Release of Information:

If you need for Ear, Nose and Throat, Ltd. to release information in your electronic medical record to another health care provider, please download the below form and fill it in and either bring it one of our offices or fax it to our secure fax number (757) 627-6471.

ENT LTD. Patient Authorization for Use/Disclosure of Health Care Information Form

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No Show Policy:

Any patient who fails to show up for a scheduled appointment and does not give sufficient notification (within 24 hours of scheduled appointment)
will be designated as No Show.

After two (2) no shows the doctor will be consulted as to the future status of the patient. It may be decided to remove the patient from the practice.

No Shows may incur a fine of $25 for the first No Show - $50 for the second No Show (unless the patient is to be removed from the practice).

Any questions may be addressed to the Business Manager / (757) 623-0526.

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Financial Policies:

This Financial Policy is designed so patients and/or parents/guardians of Ear, Nose and Throat, Ltd. understand our position on payment for services rendered by the providers.

• All new patients will be required to fill out an Ear, Nose and Throat, Ltd. Patient Information Sheet, front and back.

• The back of the form contains an explanation of financial expectations for patients and/or parents/guardians for services rendered by the clinical providers at ENT, Ltd.

• The patient will read and sign the back of the form. The Receptionists will witness the form with their signature and date it.

• The front and back of the form will be scanned into the Electronic Medical Records of the patient. The original is placed in a locked shredding bin.

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Patients With Health Insurance:

• If a patient and/or parent/guardian have health insurance, this contract is between them and their insurance carrier. The co-insurance amounts, and deductibles that have not been satisfied, are the responsibility of the patient, parent/guardian. Co-payments are expected at the time services are rendered.

• Patients with a balance owed are expected to pay the balance in full upon receipt of the invoice. Consideration will be made for extenuating circumstance, but only if the recipient notifies one of the Patient Account Representatives first.

• Patients who are unable to pay their bill or have questions are expected to contact the Patient Account Representative responsible for their account before your payment becomes overdue.

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For Self-Pay Patients:

• A standardized payment formula will be used for office visits and procedures conducted in the office. A minimum of $150 is expected prior to seeing the doctor. A pre established standard deduction will be applied by Ear, Nose and Throat, Ltd. to the office visit / procedure charge.

• Once the patient’s visit is concluded, the check out personnel will review the Superbill, if there are additional procedures marked, to include Audio, the patient will be informed that additional charges have been incurred and will be billed to the patient. It is not the front desks responsibility to inform the patient of the amount, this will be calculated by the Billing department within approximately 14 business days of the visit.

• For patients that did not have any other procedures or Audio, the patient may be eligible for a refund, but this will not be confirmed until after the Superbill has gone through Billing, in approximately 14 business days.

• When surgery is required, in most cases, a 50% down payment is expected at least one week prior to the elective surgery date. The remainder of the payments will be expected within 30 days after the surgery, unless other payment arrangements are made.

• For urgent surgeries, the Patient Account Representative from Ear, Nose and Throat, Ltd. will work closely with the patient to establish a payment plan.

• For special cosmetic cases, these will be handled on a case-by-case basis and are discussed between the patient and the doctor.

• Patient accounts are considered delinquent if no payment has been received within 30 days after the mailing of the second invoice, unless the patient has contacted the Patient Account Representative.

• These delinquent accounts are sent to the pre-collections department where attempts will be made to collect the monies owed.

• If after 60 days, no monies have been received, then the account is forwarded to a collection agency

• A finance charge will added to the account at that time in the amount of 15% of the amount owed. Accounts with a payment plan will be excluded.

• The patient is expected to pay the balance and all reasonable fees associated with the account being in pre-collections and collections.

• By signing the back of the Patient Information sheet the patient, parent/guardian acknowledge that this form is being signed in either Norfolk, VA, or Chesapeake, VA, and that services are being performed in either Norfolk, VA, or Chesapeake, VA and should a suit become necessary to collect on this account that court filings will be in either Norfolk, VA or Chesapeake, VA.

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Participating Insurances:

We participate with the following major insurance carriers: If you do not see your insurance company listed please refer to your provider manual or contact our billing office for assistance.

Aetna
Alliance PPO (Mamsi)
Anthem (BCBS, Healthkeepers)
Champ VA
Cigna (VA only)
First Health
Mail Handlers
MDIPA
Medicaid of VA
Medicaid of NC
Medicare and Railroad Medicare
Metro Machine Health Plan
Multi Plan
One Health Plan
Optima
PHCS
Tricare Standard, Prime and Tricare for Life
United Healthcare
Virginia Health Network (VHN, Beech St)
Virginia Premier

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Hospital Affiliates:

We participate with the following major insurance carriers: If you do not see your insurance company listed please refer to your provider manual or contact our billing office for assistance.
Sentara Norfolk General Hospital
Sentara Leigh Hospital
The Children's Hospital of the King's Daughters
Bon Secours DePaul Medical Center

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Otolaryngology

All things Ear, Nose and Throat by board certified physicians and surgeons

Audiology

Board certified
Audiologist to guide you
in understanding your hearing deficiencies

Allergy

Providing you allergen testing, diagnosis and comprehensive treatment for your allergies