I hereby authorize to release to the above named insurance company(s) any medical information necessary to process any of my insurance claims or the release of any facts concerning the treatment provided. I further authorize the above insurance company(s) to pay direct to Northside ENT, Inc., the medical benefits otherwise payable to me. I understand that I am financially responsible for those charges not paid by my insurance. Also, I certify that all of the above health insurance plan(s) do/do not require preauthorization and/or second opinion in connection with the services to be provided.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
I authorize that lab and x-ray results may be left on my
I request and authorize the above company, its agents and employees and my physician, their associates and assistants to perform routine medical tests and procedures to provide drugs, medical care and other services and supplies as are prescribed for my health and well-being. I acknowledge that no representatives, warranties, or guarantees as to results or cures have been made to me by the above company, nor have I relied upon any such representatives, warranties, or guarantees. I understand that attempts will be made to call me prior to my appointments. I authorize the above company to call me at the telephone numbers listed on my registration record. I acknowledge that this consent will remain in force and applies to subsequent outpatient treatment unless revoked by me in writing.
*Persons authorized under IC 16-36-1-3 to consent include a competent adult patient or an emancipated minor patient (i.e. at least 14, living apart from parent and able to support self; married, or has been married; or is in military service). If the patient is competent, consent may be provided by the patient's legal guardian or, if none, by a person appointed to do so by the patient, or if neither of the above, by the spouse, parent, adult child or adult sibling of the patient. Consent by anyone other than the patient or legal guardian cannot be contrary to the patient's previously indicated instructions concerning his health care.
*This signature applies to the Privacy Notice Acknowledgement Statement, the Authorizations for Messages, and the Consent for Outpatient Treatment.
Thank you for placing your confidence in our physicians. We wish to take this opportunity to review our payment policy for services rendered.
Please contact us with any questions or if you are unable to make a timely payment. We have a direct line to a representative who can help you. (317) 844-6403
ALL CO-PAYS are due at the time of your visit. If you are unable to pay your copay at the time of your visit, your appointment will be rescheduled.
THERE MAY BE A $20 FEE for any no shows or appointments not cancelled within 24 hours of your appointment.
DEDUCTIBLES may be collected prior to surgery as indicated by your insurance company.
METHOD OF PAYMENT Cash is best. Checks are accepted, but prepayment for surgeries will delay the surgery until the check clears the bank. Visa and Mastercard are also accepted, as well as access to a line of credit offered by Care Credit.
STATEMENTS are sent out on a monthly basis. After 30 days, you account is considered delinquent and a 1.3% interest will be added to the account balance until the account is paid in full.
DO I NEED A REFERRAL? If you are unsure, contact your insurance carrier. If your company requires a referral and we have not received an authorization prior to your arrival at our office, we will make one attempt to call your primary care physician to obtain it. If we are unable to obtain the referral at that time, your appointment will be rescheduled.
HOSPITAL, X-RAY, LAB, PATHOLOGY, AND ANESTHESIA charges are all billed separately by each facility or provider. We are not responsible for knowing rates or procedures for these bills.
ALL SERVICES WILL BE FILED WITH YOUR INSURANCE PLAN, regardless of whether we are a provider on that plan's provider panel. Please be sure we have complete information so as to avoid delays. Balances not paid or adjusted by the insurance plan will be billed to the responsible party/patient for payment.
HEARING AIDS ARE NOT COVERED BY MANY INSURANCE COMPANIES. Special payment plans can be arranged for the purchase of hearing aids.
IN THE EVENT OF DEFAULT IN PAYMENT OR IF LEGAL ACTION should become necessary to collect an unpaid balance due for medical services rendered to me or my family, I/we agree to pay attorney fees, collection agency fees and other such costs as the court determines proper.
I HAVE READ AND UNDERSTAND THE PAYMENT POLICY ABOVE. I AGREE AND UNDERSTAND THAT SUCH TERMS MAY BE AMENDED FROM TIME TO TIME BY THE PRACTICE
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application
Please indicate all past and present medical history and the dates of any surgical procedures if known.
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(List relationship to patient)
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As a current patient of Total Hearing Solutions®, a division of Northside ENT, Inc, I give authorization to Total Hearing Solutions® to send me periodic advertising and hearing aid information from either Total Hearing Solutions and/or the hearing aid companies they work with (Phonak, Signia, Cochlear, Advanced Bionics, Oticon, Caption Call, Westone). I understand that these advertising pieces may be paid for, in part, by said hearing aid companies. (*This does not include names purchased on a mailing list from a marketing company.)
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