Patient Demographics and Insurance Form

Provide your insurance card and photo ID at reception.

Please correct the errors described below.

Insurance lnformation

Acknowledgement of Receipt of Notice of Privacy Practices

By signing below, I acknowledge that I reviewed a copy of Austin Association of Otolaryngology's HIPAA Privacy Notice and Privacy Practices.

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

Consent to Treatment

By signing below, I consent to the performance of examinations, diagnostic procedures, and rendering of treatment by the medical provider and their designated medical office staff as is deemed necessary in the medical provider's judgement. I understand that I have the right to refuse any medical or surgical treatment which I do not want.

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

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

Medical History

ALLERGIES?

(Please fill out completely)

Add another allergy

MEDICAL / SURGICAL HISTORY: HAVE YOU EVER BEEN DIAGNOSED WITH ANY Of THE FOLLOWING?

Cardiovascular:

Gastrointestinal:

Genitourinary:

Earl Nose I Throat: (HEENT)

Hematologic:

Immunologic:

Infectious Disease:

Metabolic/endocrine:

Neoplastic:

Neurologic:

Obstetric:

Psychiatric:

Pulmonary:

List all Medications you are taking including prescription, over-tlle-counter and herbal:

Add medication

FAMILY HISTORY:

Cancer

Type of Tobacco

Cigarettes:

Other:

Add type of alcohol

REVIEW OF SYSTEMS:

Please mark where applicable:

General health problems

Eye problems

Ear problems

Nose & Sinus problems

Mouth & Throat problems

Heart or circulation problems

Lung or respiratory problems

Musculoskeletal

Stomach problems

Brain or Nervous system problems

Glands & Hormone problems

Blood or Lymph nodes problems

Allergy problems

Skin

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

Notice to our Patients:

The scope used to examine your nose and throat is a necessary diagnostic tool which may replace the need for additional, costly diagnostic procedures such as Computed Tomography (CT scan), in some circumstances. Additionally, please consider that the information acquired using the in office scoping procedure allows thorough, same day diagnosis in most circumstances.

Please note: this procedure, like a CT scan, MAY be subject to your deductible and/or coinsurance under your health insurance plan.

For any diagnostic procedure that is performed, you may be asked to pay the insurance allowed amount for the procedure at the time of service. Our office will bill your insurance policy and apply any contractual discounts to your balance.

Late Cancellation and "No Show" Agreement

We kindly ask you to provide 24 hours notice in the event you must cancel or reschedule an appointment. Failure to cancel or reschedule appointments 24 hours in advance will incur a $60
fee.

Thank you for your advanced notice and cooperation.

Please sign below, acknowledging the above statement and consent to the "No Show" agreement.

Medical Information Release Form

HIPAA Release Form

Release of Information

I authorize the release of information including the diagnosis, records; examination rendered to me and claims of information. This information may be released to:

This Release of Information will remain in effect until terminated by me in writing.

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