New Patient Form

New Patient Form
Patient Information
Patient's Legal Name*

First NameMiddle NameLast Name
Age*
Birthdate*

MonthDayYear
Date
Father's Name*

First NameLast Name
Father's SSN
Employer's Name*
Father's Work Phone*
Please enter a valid phone number.
Mother's Name*

First NameLast Name
Mother's SSN
Employer's Name*
Mother's Work Phone*
Please enter a valid phone number.
Sex*
Patient's SSN
How did you hear about our office?*
Race*
Ethnicity*
Language Preference*
Email Address*
example@example.com
Patient's Address*

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Business Phone Number
Please enter a valid phone number.
Patient's Employer
Employer's Address

Street Address

Street Address Line 2

CityState

Zip Code
Spouse's Name

First NameLast Name
Spouse's Phone Number
Please enter a valid phone number.
Spouse's SSN
Emergency Contact (other than spouse or parent name)*

First NameLast Name
Relationship*
Emergency Phone*
Please enter a valid phone number.
Responsible Party Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Relationship to Patient*
Billing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Family Physician's Name
Phone Number
Please enter a valid phone number.
Name of referring physician if other than family doctor
Phone Number
Please enter a valid phone number.
Has anyone in your IMMEDIATE family been seen before?*

YesNo
If yes, who*

First NameLast Name
Primary Insurance ID*
Insurance Company Name*
Policy Holder Name*

First NameLast Name
Policy Holder Date of Birth*

MonthDayYear
Date
Policy Holder Employer*
Secondary Insurance ID
Insurance Company Name
Policy Holder Name

First NameLast Name
Policy Holder Date of Birth

MonthDayYear
Date
Policy Holder Employer

PRIVATE INSURANCE AUTHORIZATION FOR ASSIGNMENT OF BENEFITS, INFORMATION RELEASE &CONSENT TO TREATMENT
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
Signature of Patient (if minor, Parent or Legal Guardian Signature)*

Clear
Date*

MonthDayYear
Date

FINANCIAL POLICY
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 is
considered a part of your treatment.
1. We accept CASH, CHECKS, VISA, MASTERCARD, DISCOVER, AMERICAN EXPRESS and CARE CREDIT.
2. Co-payments as well as outstanding balances are always due at the time of service, unless other arrangements have been
  made with the billing office. Our contractual agreement with your insurance carrier prevents us from waiving your required co-payamount.
3. The balance of the account is due within 15 days of the statement date unless you have made other arrangements with the
  business office. An Administration Feeof $10.00 will be applied to your account if full payment is not received by the statement due date. We will collect all outstanding account balances prior to each visit.
4. If you have no insurance coverage, payment of 80% of charged fees are due at the time of the visit with a minimum payment of $150.
5. Routine diagnostic procedures that are customary to our specialty and are a necessary part of your treatment may be applied toward your deductible or coinsurance depending on your individual insurance plan. It is the responsibility of the patient to know their coverage details.
6. Payment for elective services will be required 48 hours prior to service and will not be filed with your insurance company until after they are rendered.
7. A $25.00 service charge will be assessed for returned checks. If your check is returned, you will be required to pre-pay in full by cash, Visa, MasterCard, Discover, or American Express for additional services.
8. Call to correct any billing errors promptly. If you ignore our billing statements or telephone calls, we can only assume that you do not intend to pay for the medical services that were provided in good faith, and your account will be forwarded to an outside collection agency.
9. Referrals – some insurance plans require that a referral from the primary care physician be obtained prior to being seen. It is the responsibility of the patient to obtain this referral. If a referral has not been obtained you may be responsible for a larger portion of your bill.
10. Personal Injury – we will not be a party to any litigation suits filed for personal injuries. We require payment in full and any payment from litigation is to besought by you for reimbursement.
11. Work-Related Injuries – pre-authorizations for care is the responsibility of the patient. If the prior authorization is not obtained, you are responsible for full payment at the time of service. If your workers compensation carrier has not paid your account within 45 days of the date of service, the owed balance will become the responsibility of the patient.
I UNDERSTAND AND AGREE TO THE TERMS OF THIS FINANCIAL POLICY.
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Signature of Patient or Patient Representative*

Clear
Date*

MonthDayYear
Date

PROCEDURES IN OFFICE
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:
- CPT 31231 Nasal Endoscopy $515.00
  - This procedures uses a flexible or rigid scope attached to a light source to view areas of the nasal cavities that cannot be viewed by the physician using the nasal speculum and head mirror.
- CPT 31575 Flexible Laryngoscopy $335.00
  - This procedure involves passing a long thin flexible fiber optic scope through the nasal cavity and into the throat. Their fiber optic scope enables the physician to visualize areas of the throat not readily seen using laryngeal mirrors.
This list is not inclusive of all procedures that may be performed in our office.
Patient Name*

First NameLast Name
Patient/Guardian Signature*

Clear
Date*

MonthDayYear
Date

Notice of Privacy Practices & Alternate Communications
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.
***In accordance with my right for protected health information, I give you permission to discuss my protected health information with the following people (please include name, relationship, and phone number):
In accordance with my right for protected health information, my preferred method of communication is:*

PhonePatient Portal (See Receptionist)Postal Mail
Phone Number*
Please enter a valid phone number.
Can we leave a message on this phone number?*

YesNo
In the event that we are unable to contact you via your preferred method of communication, how do you want to be contacted?*
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.
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Signature of Patient or Patient Representative*

Clear
Date*

MonthDayYear
Date

ENT CONSULTANTS, LLC – MEDICAL HISTORY & SYMPTOMS
***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.”***
Name*

First NameLast Name
Date of Visit*

MonthDayYear
Date
PATIENT MEDICAL HISTORY:
Height*
Weight*
If female, are you or could you be pregnant?*

YesNo
If yes, # of weeks?*
MEDICATION & PERSONAL MEDICAL HISTORY: (MUST PROVIDE A LOCAL PHARMACY)
Local Pharmacy with Address (i.e. Walgreens 90th& Dodge)
Mail-In Pharmacy:
MEDICATION ALLERGIES (LIST ALL):
CURRENT MEDICATIONS:
OTHER PERSONAL ILLNESSES NOT LISTED ABOVE:

FAMILY MEDICAL HISTORY (IF NONE OR UNKNOWN PLEASE INDICATE THIS BELOW):

Please, only include blood relatives!!!
CANCER SCREENINGS (year):
IMMUNIZATIONS (year):
If you have received the Covid-19 Vaccine, which manufacturer did you receive?*

PfizerModernaJohnson and JohnsonI did not receive a Covid-19 Vaccine
PREVIOUS SURGERIES (LIST ALL AND IF NONE PLEASE INDICATE THIS BELOW):

REVIEW OF TODAY’S SYMPTOMS: (Mark all that apply)
General
Cardio
Skin
Eyes
Cardio
Cardio
Gastroint
Cardio
Cardio
Cardio
Endocrine
Cardio
Allergy
ENMT
List any other symptoms here
Should be Empty:

Patient Information

PRIVATE INSURANCE AUTHORIZATION FOR ASSIGNMENT OF BENEFITS, INFORMATION RELEASE &CONSENT TO TREATMENT

FINANCIAL POLICY

PROCEDURES IN OFFICE

Notice of Privacy Practices & Alternate Communications

ENT CONSULTANTS, LLC – MEDICAL HISTORY & SYMPTOMS

PATIENT MEDICAL HISTORY:

MEDICATION & PERSONAL MEDICAL HISTORY: (MUST PROVIDE A LOCAL PHARMACY)

SOCIAL HISTORY:

FAMILY MEDICAL HISTORY (IF NONE OR UNKNOWN PLEASE INDICATE THIS BELOW):

REVIEW OF TODAY’S SYMPTOMS: (Mark all that apply)