Financial Policy Agreement

FInancial Policy

The ENT Center is committed to providing the best possible care for our patients. All paperwork must be filled out prior to seeing the physician. We will need to scan or photocopy your insurance card(s) and your photo identication when you check in for your appointment. Your clear understanding of our Financial Policy Agreement is important to our professional relationship. Please let us know if you have any questions regarding our fees or your financial responsibility.

  • Appointments - Please provide at least 24 hours notice when cancelling an appointment. Failure to appropriately notify the office of a cancellation may result in a "No-Show" fee of $25.00. If your appointment requires an interpreter, please provide at least 72 hours notice when cancelling an appointment. If you fail to appropriately notify the office of a cancellation, you may billed for the interpreter services and a "No-Show" fee of $25.00.
  • Forms - There is a $30.00 charge forthe completion of FMLA, disability and life insurance forms. This fee will be collected priorto the delivery of the forms.
  • Referrals - If your insurance plan requires a referral from your primary care physician, it is your responsibility to obtain the referral priorto your appointment. If our office has not received the referral your appointment may need to be rescheduled.
  • Co-payments - By law and as required by the insurance company, we must collect your designated co-pay. This payment is collected at the time of check-in. If you do not have your co-pay at check-in, your appointment may need to be rescheduled.
  • In Office Procedures - As part of your exam or post-operative care, in office procedures such as scopes, biopsies and cauterization, may be needed to further assess your condition. Some in office procedures may not be covered by your insurance. You are responsible for the balance not covered by your insurance carrier.
  • Insurance - We will submit a claim to your insurance carrier. All patients are responsible for their co-pay and deductible. If we do not receive payment from your insurance carrier within 45 days, you will receive a statement in the mail for the full amount of the charges.
  • Non-Participating Plans - If we do not participate with your insurance, you will be required to pay a deposit for services at the time of check-in. You will receive a statement in the mail for the remaining balance of the charges. It is your responsibility to pay this balance. Once you have paid in full, you may submit the claim to your insurance for reimbursement.
  • Self Pay Patients - The ENT Center offers a discount for all self pay patients when they pay for their visit on the day of service. You will be required to pay a deposit for services at the time of check-in. The remaining balance/credit will be sent to you via mail. In office procedures must be paid for at the time of check-out to receive the discount. If surgery is needed, The ENT Center requires a deposit equal to 50% of the estimated surgery charges to be paid at least 10 clays priorto the date of surgery. The remaining balance is due within 30 days afterthe date of surgery. Forthose that would like to pay the balance in full priorto surgery, a 15% discount may be applied. Please discuss surgical charges with the Surgical Coordinator.
  • Worker's Comp and Auto Insurance Claims - We will submit a claim on your behalf. You will need to provide us with the claim number and a copy of your notification of Compensation Payable. In addition, you will need to provide us with your medical insurance information. If your Worker's Comp/Auto Insurance claim is denied, we will bill your medical insurance. You are responsible forthe balance not covered by your insurance.
  • Consent for Treatment (Adult) - Patients overthe age of 18 who are unable to consent to their own medical treatment, complete necessary paperwork, or communicate the reason fortheir visit must be accompanied by their Power of Attorney (POA). If the POA has completed all of the necessary paperwork and has appointed another person ortreatment facility to consent to medical treatment in their absence, the POA need not be present.
  • Consent for Treatment (Minor) - Guardians, Foster Parents and all non-biological persons who bring a minor patient to their appointment will be required to present court orders and/or other documentation proving that they have been given authority to consent to the minor patient's medical treatment. Please contact the office priorto the appointment to make arrangements to obtain all required paperwork. Prior to the appointment, please verify that we have received your completed paperwork. Failure to complete paperwork in its entirety, or to provide appropriate documentation may result in the need to reschedule the appointment.
  • Divorced/Separated Parents of Minor Patients - The parent that consents to the treatment of the minor is responsible forthe payment of services rendered. The ENT Center will not be involved with any separation, divorce or custody disputes.
  • TELEMEDICINE - I understand that if I elect to have Telemedicine services (examination and treatment via phone/video/patient portal) these services may be subject to my deductible, copay and co-insurance. I authorize The ENT Centerto bill my insurance carrier for Telemedicine services and understand that I am responsible for payment not covered by my insurance carrier.

By signing below, I am authorizing the payment of medical benets be made to The ENT Centerfor all services rendered. I understand that I am responsible for the payment of all services rendered that are not covered by my insurance. I authorize The ENT Centerto release information regarding my health care, treatment or supplies, to my insurance carrier. This information will be used for the purpose of evaluation and payment of claims.

Additionally, you agree, in orderfor us to service your account or to collect monies you may owe, The ENT Center, and or our agents may contact you by telephone at any telephone number associated with your account, including wireless telephone numbers, which could result in charges to you. We may also contact you by sending text messages or emails using any email address you provide to use. Methods of contact may include using prerecorded/articial voice messages and/or use of automatic dialing device as applicable.

I / We have read this disclosure and agree that The ENT Center, its employees and/or agents may contact me/us as described above.

Parent / Legal Guardian

Please use the section below if you are signing on behalf of a minor or as a legal guardian

submitting