Notice of Privacy Practices
Assignment of Insurance
The undersigned hereby assigns to Austin Association of Otolaryngologists all rights, title and interest in any payment due patient and/or undersigned for medical care, services, or supplies described in any health insurance claim form or statement issued by indicated entity. The undersigned understands that this agreement will not eliminate or affect in any way the obligation of the patient and/or undersigned to pay the indicated entity for all services and supplies rendered, including but not limited to, any copayments or deductibles required by a particular healthcare program or plan.
Release of Medical Information
I hereby authorize the release of any medical record of all results of any testing and other pertinent information acquired during my treatment to the physician as deemed necessary. I agree that a digital image of this authorization shall be considered as effective and valid as the original.
Responsibility of co-payment/ deductible, lab and referrals
Based on the particular plan of insurance carried by the patient and/or insured, and such financial responsibilities set forth within their policy shall be made payable during that particular visit to the provider. These include co-payments, deductibles, and co-insurance when deemed appropriate. The patient and/or insured also agrees that it is their responsibility to obtain any referral deemed necessary by their health plan in order to be seen by a provider in this office. Patient also acknowledges that they will be financially responsible for visits that were not authorized by their health plan. It is the responsibility of the patient/insured to be aware of which lab company is their health plan network.
If you need to cancel your appointment, please notify us at least 24 hours in advance of your scheduled appointment. We will assess a $60 fee for each cancellation or no show without the required 24 hour cancellation notice.
Results of tests
It is the expressed policy of this office that no patient shall receive the results of any diagnostic or laboratory testing by means of telephone or written letter unless previously agreed to and documented in the medical record by the provider.
By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application