Patient Forms
Your First Visit Take a moment and look over the forms we require for your visit. At your 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, click…
Insurance
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…
Financing
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…
HIPAA Statement
NOTICE OF HIPAA PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Our legal Duty: We are required by applicable federal and state law to maintain the privacy of your health information. We are also required…
