I, the undersigned, authorize payment of medical benefits to Ear, Nose & Throat Consultants, LLC for any services furnished to me by the physicians. I understand I am financially responsible for any amount not covered by my insurance contract. I also authorize you to release to my insurance company information concerning health care, advice, treatment or supplies provided to me. This information will be used for the purpose of evaluating and administering claims of benefits.
I, knowing that I have a condition requiring diagnosis, treatment, or related medical care do hereby consent to such care, medical examination(s), operation(s), procedure(s), therapy sessions, photographs, and/or treatment by my attending physician(s), their assistant(s) or designee(s) as may be necessary in their professional judgment. I further acknowledge that no guarantees have been made to me as to the results of such care, medical examination(s),operation(s), procedure(s), therapy sessions and/or treatment
Thank you for choosing Ear, Nose & Throat Consultants, LLC for your health care needs. All patients must accept our FINANCIAL POLICY before receiving treatment. Please understand that full payment of your bill isconsidered a part of your treatment.
I UNDERSTAND AND AGREE TO THE TERMS OF THIS FINANCIAL POLICY.
Your Primary Care Physician referred you to a specialist because we have specialized equipment to diagnose and treat you. Please be aware that certain procedures performed in our office are not included in the standard office visit. These procedures will be billed separately and in addition to the office visit charges. Insurance carriers often classify these procedures as surgery and apply the charges to your calendar year deductible. This is plan specific with your insurance. High deductible plans may apply patient responsibility for both the office visit and the procedure. Traditional plans may apply a copayment for the office visit, and deductible for any procedures. In either case, payment of the procedure will be due from the patient. Be assured that we are following all federally accepted billing and coding guidelines.
The physicians of ENT Consultants only perform procedures when deemed medically necessary to best diagnose and treat our patients. If you are presenting with sinus, throat/voice complaints, or have had past sinus surgery, there is a good chance that our providers will determine it necessary to perform one of these procedures to properly diagnosis and treat you.
Examples of in-office procedures and their estimated costs include:
This list is not inclusive of all procedures that may be performed in our office.
The Notice of Privacy Practice describes how medical/protected health information about you may be used and disclosed and how you can get access to this information.
In summary, as a patient you have the right to access your protected health information. You also have the right to request corrections to your information, request your information be restricted, and request confidential communication. We want to assure you that your medical/protected health information is secure with us. You also have a right to request a detailed Notice of Privacy Practice of the Medical Practice named at the top of this page at any time.
I acknowledge that I was notified of my HIPAA rights and my right to obtain its full details. I also have exercised my right to name or not name any alternate individuals to receive my protected health information as well as indicated my preferences regarding how I would like to receive my protected health information.
***This information is needed to ensure that you receive the best care possible. Please fill out completely. If any field is left blank, it will be assumed that the answer is “NO.”***