Patient Forms

Insurance Information
Primary*

MedicareState WelfareOther Insurance
Name of Insured*
ID#*
Group #*
Date of Birth*
Secondary

MedicareMedicaidOther Insurance
Name of Insured
ID #
Group #
DOB
Is it Worker's Compensation?
If yes, name of your company & contact person
Which provider are you seeing?*
Referring Doctor's Address
Referring Doctor Phone
Referring Doctor
Referring Doctor Fax
Primary Care Doctor*
Primary Care Doctor's Address*
Primary Care Doctor's Phone*
Primary Care Doctor's Fax*
If we participate with your insurance company we will submit your claim to them, but we cannot be responsible for errors or delay in the filling out and/or submission of insurance forms if we do not have the proper insurance card.

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Regardless of any insurance coverage I/we may not have, it is my/our responsibility to pay the entire bill. In the event that this office needs to obtain legal assistance in collection of any unpaid balance, I/we agree to pay costs and attorney fees, as allowable by law and acknowledge receipt of a photocopy of this agreement.

By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.
Signature*

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Signature*
Patient/Responsible Party Signature

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Patient/Responsible Party Signature
Authorization to release my medical records for billing purposes is granted by me.
Signature*

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Signature*
Parent/Responsible Party Signature

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Patient/Responsible Party Signature
PLEASE PRESENT INSURANCE CARD AT THE TIME OF EACH VISIT.

Acknowledgment of Receipt of Notice of Privacy Practices
Name of Patient*
I hereby acknowledge that I received a copy of this medical practice's Notice of Privacy Practies. I further acknowledge that a copy of the current notice will be posted in the reception area, and that I may request a copy of any amended Notice of Privacy Practices at each appointment.
HIPAA Questions
As my doctor, you or your staff may: (PLEASE CHECK ALL APPROPRIATE BOXES)*

Call my home/cell phone and if necessary leave a message on the answering machine/ voice mail/with a family member for me to call you back to schedule an appointment or to return your call.Call my home/cell phone and if necessary leave a message on the answering machine/voice mail/with a family member giving the results of a test.Call my home and if necessary leave a message on the answering machine/voice mail/with a family member inquiring how I am doing.Call my workplace and if necessary leave a message for me to call you back to schedule an appointment or just to return your call.
HEALTH PLAN REQUIREMENTS. I am responsible for knowing my medical policy and am responsible for charges if any of the following apply:
- My health plan requires prior authorization or referral by a primary care physician (PCP) before receiving services at Southern New England Ear, Nose, Throat and Facial Plastic Surgery Group, LLP (SNEENT), and I have not obtained an appropriate and accurate authorization or referral;
- I receive services in excess of such authorization or referral;
- My health plan determines that the services I received at SNEENT are not medically necessary and/or not covered by my insurance plan;
- My health plan coverage has lapsed or expired at the time I received services at SNEENT;
- I have chosen not to use my health plan coverage.
I agree with all the above terms.

By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.
Signed*

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Signed*
Date*

MonthDayYear
Date
Print Name*
Telephone*
If not signed by the patient, please indicate your relationship to the patient:*

Welcome to Southern New England ENT & FPS Group!

Thank you for choosing our practice for your ear nose, and throat medical/surgical care. Our physicians, PA's, and staff will provide you with caring attention and professional healthcare.
Insurance and Credit Cards

We accept insurance assignment for your visits, and recognize that many of the commercial insurance plans have a high deductible causing a large balance on your account. In order to increase our efficiency, we require a credit card at the time of check-in to cover these high deductibles (NOT applicable to Medicare or Medicaid patients).

The information will be held in a completely secure area until it is determined what your balance is. It can take up to 2-3 weeks before we recieve an insurance Explanation of Benefits (EOB). Once recieved, we will call you for permission to use your credit card. If you are not at home, we will leave a message for you to call us back. If we do not hear from you in two (2) busines days, we will proceed with payment processing on your credit card, and will send you a copy of the credit card authorization and the EOB. Your signature below allows us to proceed as outlined.

Rest assured that we take every safety precaution to protect your information in a locked and secure location with NO online or computer exposure. This avoids the inconvenience of mail-in payments or calling in credit card numbers. We will still expect co-payments at the time of your visit.

By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.
Signature*
Signature*

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Printed Name/Relation*
Date*

MonthDayYear
Date
NO SHOW POLICY AGREEMENT
If you cannot make your scheduled appointment for any reason, please call our Scheduling Department at 203-787-4951 at least 24 hours before your scheduled appointment to cancel or reschedule. There will be a $25.00 charge for missing an appointment without a 24 hour notification call.

Patients that NO SHOW (do not provide a notification call to cancel) three (3) or more times in a 12 month period may be dismissed from the practice and will be denied any future appointments.

Thank you for your cooperation and understanding. Please sign below that you agree to these terms.

By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.
Signature*

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Signature*
Printed Name/Relation*
Date*

MonthDayYear
Date
Informed consent for office visit/treatment/surgery COVID-19 Risk

Effective for 3 months from Date of Signature
TO OUR PATIENTS: We are currently in the midst of a worldwide disease pandemic caused by the COVID-19 virus, also known as SARS CoV2. The Centers for Disease Control and World Health Organization have identified COVID-19 as a health threat that is both highly dangerous and highly contagious. The virus can be spread by any person-to-person contact including contact with healthcare providers. While the risks from the COVID-19 virus are expected to diminish with time, they are likely to be with us for a long time and there may never be a time when the risks from COVID- 19 are zero. Because of this, patients must be aware that their decision to proceed with an OFFICE VISIT, ELECTIVE SURGERY, PROCEDURE, OR TREATMENT carries an unavoidable risk that they might contract the COVID-19 virus.

At Southern New England Ear Nose Throat & Facial Plastic Surgery Group, LLP, we are taking many precautions to prevent the spread of the COVID-19 virus and to make our patients safe when they come to us for medical care. This includes training of our personnel, using appropriate personal protective equipment and adhering to guidelines published by major health organizations for the safe delivery of medical care. Despite this, however, the risks presented by the COVID-19 virus can never be eliminated. For these reasons, we are taking special steps to inform our patients about the risks, benefits and alternatives to receiving medical care during the COVID-19 pandemic.

CONSENT TO TREATMENT:
- I understand that choosing to receive elective medical care during the COVID-19 pandemic can result in a positive COVID-19 diagnosis for me or for those with whom I may come in contact, and may cause harm to me or to them including a positive COVID-19 diagnosis, additional tests, hospitalization that may require medical therapy, intensive care treatment, possible need for intubation/ventilator support, short-term or long-term intubation, other potential complications that may at present be unknown, and the risk of death.
- I understand that even though I may have received a negative test result for COVID-19, the test may have failed to detect the virus or I may have been exposed to the virus after the test.
- I have been given the opportunity to discuss the risks, benefits and alternatives available to me and to postpone my office visit, surgery, procedure, or treatment to a later date when the risks from COVID-19 may be lower.
- I have been given the opportunity to have my questions about COVID-19 risks addressed.
With these understandings, I choose to proceed with MY OFFICE VISIT, SURGERY, PROCEDURE, OR TREATMENT.

By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.
Surgery/Procedure*
Patient Signature*

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Patient Signature*
Date*

MonthDayYear
Date

How did you learn about our practice?*

Referring doctorPatient, family member, or friendWebsiteSocial mediaOther
If you selected "Referring doctor" or "Patient, family member, or friend" above, whom may we thank for referring you to our office?
Would you like to receive emails for future specials, promotions and educational seminars on aesthetic/cosmetic procedures?*

YesNo
Warning Regarding HIPAA and Text/Email Communications

The Providers and staff at SNEENT take every step possible to maintain your privacy and to stay compliant with all HIPAA laws. However, at this time in technology it is not possible to ensure complete privacy between you and our practice for email and text communications. In other words, if you are to text or email any of your medical information or photos to our practice it cannot be guaranteed that all of the information is compliant with HIPAA privacy laws and it is possible that some of it could be inadvertently exposed. For this reason, we want to make clear that HIPAA compliance is not possible for all text and emails between you and the Providers and staff at SNEENT and you should be warned of the possibility of sensitive information being unprotected. Your signature below memorializes your understanding of this important issue.

By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.
Signature*

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Signature*
Should be Empty:

If the patient is a minor, student, or another party is responsible for payment fill out this section.

Insurance Information

Review of systems (check all)

Acknowledgment of Receipt of Notice of Privacy Practices

HIPAA Questions

Welcome to Southern New England ENT & FPS Group!

NO SHOW POLICY AGREEMENT

Informed consent for office visit/treatment/surgery COVID-19 Risk