• Financial Agreement and Office Policies

    Downtown ENT
  • Thank you for choosing Dr. B. Thuy Le at Downtown ENT for your ENT specialty care. We strive to serve you with the utmost professionalism and to provide the best treatment options. Please take the time to read our office policies, as we would like to ensure a smooth and pleasant visit and prevent financial confusion afterwards. If you have any questions, feel free to reach out to our office regarding any fees and financial responsibilities.

    Required forms: Patient Information, Financial Agreement, Medicare Assignment of Benefits (AOB) or waiver, Health Insurance Portability And Accountability (HIPAA) and privacy forms.

    In-Network: We will confirm your active insured status and eligibility and that Dr. Le has an In- Network contract with your plan.  We will also inform you of copayments or deductible amounts that are applicable to your visit.

    Out-of-Network: We will advise you if the doctor is Out-of-Network with your plan and inform you of any pertinent cost.  You are required to pay your deductible at the time of service as contracted by your carrier.

    Referrals: HMO and some EPO insurance require a referral from their primary care physician.  Please call your PCP to obtain a referral PRIOR to your scheduled appointment. It must be done before the visit.  Without a referral, you will be responsible for the cost your office visit out of pocket because we are unable to submit the claim for the office visit to your insurance company.

    Copayment: Copayments are contracted amounts between you and your insurance company for each office visit (contractual cost-sharing).  You are required to pay your copayment at each office visit.  Dr. Le is an ENT specialist and therefore you may have a copay here even if you do not at your PCP (specialist copay, surgery specialty copay).  If you are not paying your copay at the visit, a statement will be issued to you.  This cannot be waived under contract rules.

    Coinsurance: Coinsurance is a percentage of the visit cost you are responsible for based on the type of visit you have and all its associated costs.  The difference between coinsurance and a copay is that a copayment is a set flat rate, and coinsurance is a percentage and therefore varies. Please contact your insurance company for further explanation, as the percentage of plans can be different in different settings (office vs. hospital vs. diagnostics).

    Uninsured/Self-Pay Patient: Self-pay patients sign an estimate form which states the estimated costs prior to the visit.  The final cost is determined by the level of detail of the visit and any procedures performed during the visit.

    Medicare:  Medicare patients are expected to sign Medicare Assignment of Benefits at initial visit and every 6 months. This will allow the office to send billing and medical records to Medicare when required by all contracted Medicare providers who are regularly monitored by CMS.  Please provide us with your secondary insurance, since Medicare alone covers 80%.  If you do not have secondary coverage or do not provide the secondary, you will incur a bill for the remaining 20%.  Signing this form constitutes the initial assignment of benefits to Dr. Le from Medicare by the insured.

    Nasal Endoscopy/Fiberoptic Laryngoscopy/Diagnostic Procedures: To provide you with the best care, Dr. Le will commonly perform a nasal endoscopy or laryngoscopy with a flexible or rigid fiberoptic telescope in order to diagnose you properly.  Any diagnostic procedure is done if it is essential and necessary to evaluate you and there is no substitute.  These are separate charges on a bill for the visit, whether it is a bill to insurance or a bill to you if you do not have insurance.  You may be responsible for a deductible or coinsurance for these diagnostic procedures if your insurance applies the allowable charges to your deductible and/or coinsurance.  If you prefer not to have a diagnostic done, you may sign a refusal of service.

     

  • I have read, understand and accept this section "Nasal Endoscopy/Fiberoptic Laryngoscopy/Diagnostic Procedures"   *   

  • Cancellation fees: Fees apply if you cancel a visit with less than 24 hours notice, if you cancel an office procedure fewer than 2 business days in advance or if you cancel a surgery fewer than 7 business days in advance.  If you cancel surgery two times or more, you will be charged an administrative fee of $200 each cancellation.  Please understand that surgery scheduling, booking and obtaining authorization require a great deal of work and must be repeated each time a surgery is planned.

    Minors: All minors (under the age of 18 years old if unemancipated) must be accompanied by a parent or legal guardian at every office visit. If accompanied by another adult, please provide a letter of permission stating the person’s name, their relationship to the minor, and your immediate contact information for us to verify.

    Medical Records: Your medical records are accessible to you in hardcopy with a signed medical release.  Please give us ample notice if you request paper copies, as it will take at least 5 business days to prepare. If you would like your records released to another adult (family member, spouse) a proxy form is required to release information to the designated person. This applies to any children who are adult age (age 18 and above).

    Telemedicine: Your visit is HIPAA-compliant if conducted on the telehealth portal.  It may not be fully compliant via zoom, FaceTime or Google Meets if you choose one of those platforms.  The assessment may be limited due to lack of physical exam, and you agree that this will not be held against Dr. Le or Downtown ENT.  You will receive the best care possible within the natural limitations of this modality.

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    All payment is due at the time of service. Copays, deductibles, coinsurance, self-pay fees and statement balances will be collected at your visit. 

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    I hereby have fully read and agree to Downtown ENT financial and office policies.  I agree to all terms listed above and authorize Dr. B. Thuy Le to release medical information to my insurance company to assure payment for any medical treatment under her care. Any charges not covered by insurance company (copayment, deductibles, coinsurances, out of pocket cost) are to be billed directly to me or the guarantor of my account.  I agree to be contacted by the office or an office representative for any inquiry concerning my account via all addresses, phone numbers and email addresses listed on my account.  Policies subject to change without notice.

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  • If someone other than the patient is financially responsible, please sign below:

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