New Patient Packet Forms

Please correct the errors described below.

Photo I.D and Insurance card(s) are required at every patient appointment to verify identity - per FTC guidelines

Thank you for choosing ENT Surgical Associates! ALL information is kept confidential. If the information you provide is not correct - we cannot process your claim through your insurance company. ALL copays are due at the time of service.

RESPONSIBLE PARTY INFORMATION (If it is NOT the patient)

(write same - if address is the same as patient)

PRIMARY INSURANCE INFORMATION

SECONDARY INSURANCE INFORMATION (ONLY IF APPLICABLE FOR PATIENT)

I authorize release of any information concerning my (or my dependent's) health care, advise and treatment providing for the purpose of evaluating and administering claims for insurance benefits. I also hereby authorize payment of insurance benefits payable to the insured party to be directly paid to ENT Surgical Associates of Central Georgia, PC and/or ENT Surgical Center of Central Georgia, Inc. I understand that I am financially responsible for any charges not covered by my insurance, and they are due in full upon receipt of notice. ALL information use for any purpose will be within the guidelines stated in our patient privacy policy according to HIPAA Law. ENT Surgical Associates and ENT Surgical Center are separate facilities and are billed separately. ALL Claims are filed to the insurance company as a courtesy to our patient - but if the claim is denied the patient or the responsible party will be held responsible for payment(s). Any out-of-network claims for the ASC that have been paid to the insured party must be remitted immediately or the patient/insured party will be responsible for the account in full upon receipt. signing below states you verify all information to be complete and accurate and understand our policy for insurance processing and payment(s) to our practices. The Insurance company is responsible for the patient's policy and it is a contract between the Policy holder and the Insurance Company. 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.

PLEASE TAKE AN ADDITIONAL MINUTE TO TELL US HOW YOU HEARD ABOUT OUR OFFICE...

INSURANCE CARD AND PICTURE I.D. ALSO REQUIRED - WE CANNOT FILE A CLAIM TO THE INSURANCE WITHOUT THE INSURANCE CARD. THANK YOU. FORM MUST BE COMPLETED AND SIGNED OR INSURANCE CANNOT BE PROCESSED. PAYMENT(S) REQUIRED IN FULL BEFORE APPOINTMENT WITH PROVIDER.

ENT SURGICAL HEALTH HISTORY FORM

Review of Symptoms - Check only the ones you NOW have or have had RECENTLY, if there are no symptoms check NONE

MEDICATIONS: List all medication you are currently taking. Include ALL medication even over the counter ones.

Add another Medication

Add Another Allergy

PAST MEDICAL HISTORY - Please provide a complete history including all illnesses, injuries, hospitalizations, and operations

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Has the Patient Listed Tested Positive for any of the following:

FAMILY HISTORY - Please list all Blood Relatives with their current health status and any illnessess that they have, had or have:

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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.

ALL INFORMATION IS REQUIRED TO BE COMPLETE AND ACCURATE, INSURANCE COMPANIES REQUEST THIS INFORMATION TO VERIFY CLAIMS THAT ARE PROCESSED, THIS FORM WILL BE UPDATED ANNUALLY

IDENTITY THEFT PREVENTION POLICY

Effective May 1, 2009 the staff of E.N.T Surgical Associates of Central Georgia will be required under the Federal Trade Commission (FTC) to verify your identity. Upon time of patient registration/check-in for ALL appointments, you will be required to provide either a driver's license or other photo I.D. and current health insurance card(s). If the photo I.D. does not show your current address, please bring a utility bill to show proof of address. The parent or legal guardian of a minor (patient under the age of 18) should bring the above stated information. E.N.T. Surgical Associates reserves the right to decline services if you fail to provide the necessary information. This is requirement by the FTC to protect your identity. E.N.T. Surgical Associates is bound to protect ALL sensitive patient health information under the HIPAA security standards.

CANCELLATION FEE POLICY EFFECTIVE 01/01/2010

This notice is to inform ALL patients that as of January 01, 2010 if the patient does not cancel their scheduled appointment 24 HOURS before the appointment there will be a $50.00 fee applied to their patient account. Please contact our office with any questions. This fee will not be billed to the insurance policy. It is the patient responsibility in full. Fee is required to be paid in full to schedule any future appointment. 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. This fee has been established due to the amount of patients not keeping their scheduled appointments and appointments are not available for other patients requiring medical treatment. I hereby acknowledge that I have provided E.N.T Surgical Associates with the correct proof of identification. By signing below and initialing by each policy, I certify that I have read and fully understand the policies listed above. 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.

ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE:

I have been presented with a copy of ENT Surgical Associates of Central Georgia P.C. Notice of Privacy Policies, detailing how my information may be used and disclosed as permitted under federal and state law. I understand the Contents of the the Notice, and I may request restriction(s) concerning the use of my personal medical information (PMI).

Futher, I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits either to myself or to the party who accepts assignment. Regulations pertaining to medical assignment of benefits apply. 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.

*** if not signed by the patient, please indicate relationship to the patient (i.e. spouse, mother)

By initialing this each year your medical and demographic information continues to be used and disclosed as directed above and according to the Notice of Privacy Policy.

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INTERNAL USE ONLY:

If the patient or patient's representative refused to sign acknowledgement of receipt of notice, please document the date and time the notice was presented to the patient and sign below:

FOR OFFICE USE ONLY:

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Authorization and Financial Policy

Authorization for Treatment:

I present myself or child for whom I am guardian for evaluation, and treatment or surgical procedure(s) that may be ordered or required during my treatment by Dr. Toland his assistants. or his designee and authorize any emergency medical care. I understand that the practice of medicine is not an exact science and that NO GUARANTEE OR ASSURANCE HAVE BEEN MADE TO ME concerning the results of any procedure or treatment as a result of the examination by ENT Surgical Associates, ENT Surgical Center, Dr. A. Daniel Toland or Eric Burch, R.N., MSN, FNP-C.

Billing for ENT Surgical Center:

I understand that by having services provided by ENT Surgical Associates and ENT Surgical Center that I will be billed for the facility. I accept full responsibility for both accounts that I will have with Dr. Toland. I understand that I am responsible for any monies no payable to ENT Surgical Center outside the allowable fee schedule agreed upon by my insurance(s) and ENT Surgical Center. *****Our Center may be out of network with your insurance company, but it will be treated as an in network facility. In most instances, your insurance company will be mailing the payment for services rendered by Dr. Toland and/or ENT Surgical Center to the insured party. Remember that these monies are for the surgical services already performed and we are obligated and will ask prompt payment oncer you receive payment. ***** I fully understand that any payment mailed to the insured party are my responsibility and I will remit the payment to the ENT Surgical Center upon receipt of the payment.

Medicare/Medicaid Patient's Certification:

I certify that the information given by me in applying for payment under Title XVII of the Social Security Act is correct. I request payment be made directly to the provider of services on my behalf and I authorize said provider to release any and all information necessary regarding the treatment and services as stated below.

Assignment of Benefits:

I hereby authorize payment directly to ENT Surgical Associates or ENT Surgical Center by my insurance company(s). In the event an overpayment is made from more than one insurance company, I understand the overpayment will be sent to the appropriate payer.

Surgery Services Provided:

I hereby understand that all ENT Surgical Associates and ENT Surgical Center surgery procedures are to be paid in full before services are rendered. In the case that the patient is self-pay, payment can be made with credit card, money order, or cash. In order to pay for surgery by check, payment must be presented at least 10 days in advance to the office.

Insurance:

ENT Surgical Associates and ENT Surgical Center will file your insurance as a courtesy to you. If our office does not hear from your insurance company within 30 days, we request your help in contacting your Insurance Company to resolve the payment delay. The Insurance plan is a contract between you and your Insurance Company. We must hold you responsible for any balance due.

Referrals:

I understand that my insurance may require an authorization before services can be rendered. I hereby agree to obtain any referrals and authorizations for any visits necessary. I hereby understand that any services rendered without a referral authorization will in turn be my financial responsibility.

Payment of Services:

I understand I am financially responsible for all charges and fees related to the services rendered to me by ENT Surgical Associates and ENT Surgical Center.I understand that all copays and deductibles are due at the time of service. I further understand that payment in full is expected upon receipt of the first statement and/or prior to additional office visits. this may include co-payments,additional deductibles and any services not covered by Insurance. I further understand that all post-dated checks will not be accepted. I also understand that if I am self-pay that payment is due on the date of service.

Fees:

I understand that ENT Surgical Associates and ENT Surgical Center may charge $ 30.00 or 5% of the face amount of the instrument; whichever is greater, in addition to any institutional fees for a returned check. I further understand that if payments are not made as stated I agree to pay all reasonable legal fees and cost of collection to the extent permitted by law. I also agree that this contract cannot be substituted by and Debt Management Program proposal. In the event the balance due is not paid within 90 days of 1st statement, I accept the fee charged as a legal and lawful debt and agree to pay said fee, including any/all collection agency fees, (33.33%), attorney fees and/or court costs, is such be necessary.

Consent to Contact By Cell Phone:

You agree, in order for us to service your account or to collect monies you may owe, ENT Surgical Associates and/or our agents may contact you by telephone numbers, which 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 pre-recorded/artificial voice messages and/or use of automatic dialing device, as applicable.

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.

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