New Patient Forms

Please correct the errors described below.

Patient Information

Preferred Contact Phone Number

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Referring Physician

Please print the name and relationship of the persons you authorize to receive protected health care information:

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Insurance Policy Information




Assignment of Benefits / Release of Information

I assign and request payment of medical benefits be made to HEAD AND NECK ASSOCIATES OF ORANGE COUNTY, INC. for medical services rendered. I authorize the release of medical information necessary to process my claim. I also authorize that I may be contacted via any of the above contact information I have provided. I have read the Financial Policies and understand that I am financially responsible for any non-covered services.

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.

Financial Policies

Head and Neck Associates will submit claims to your insurance company for all medical services rendered. We will attempt to verify eligibility and benefits with your insurance company; however, this verification is not a guarantee of payment. Any expenses deemed not covered by your insurance company will be your financial responsibility.

All monies owed by the patient, i.e., office visit copayments and non-covered services or supplies are due at the time of service. Also, when applicable, coinsurance percentages and/or deductibles may be collected at the time of service. Please be aware that this office will bill only for the physicians’ services. Any other services related to your office visits, i.e., laboratory, radiology or pathology will be billed by the facility providing these services.

It is your responsibility to provide Head and Neck Associates with proof of insurance and an authorization number or referral when applicable. If these items are not provided we ask that you pay in full at the time of service.

The contract between Head and Neck Associates and your health plan, as well as the contract between you and your health plan requires that you make payment in full of all co-payments and deductible amounts deemed to be your responsibility upon claims processing. Additional discounts are forbidden by contract unless financial hardship is documented in writing by the patient.

Our office accepts the following forms of payment: most major credit cards, cash, and personal checks. A $20 service charge will be assessed to your account for any check returned by your bank.

Acknowledgement of Receipt of Notice of Privacy Practices

I hereby acknowledge receipt of the Notice of Privacy Practices being adhered to by Head and Neck Associates of Orange County. The Notice of Privacy Practices is supplied in accordance with the Privacy rule that is an integral part of the Health Insurance Portability and Accountability Act (HIPAA) of 1996.

A physical copy of the HIPAA Acknowledgement can be provided upon request.

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.

Open Data Base Notice 2023

Patient we are required by the State of California to provide you with this notice of the Open Payments Database.

The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at For informational purposes only, a link to the federal Centers for Medicare and Medicaid Services (CMS) Open Payments web page is provided here. The federal Physician Payments Sunshine Act requires that detailed information about payment and other payments of value worth over ten dollars ($10) from manufacturers of drugs, medical devices, and biologics to physicians and teaching hospitals be made available to the public.

Patient Questionnaire

Personal History

Please select the symptoms that apply to why you are being seen by us today:

Please list all Allergies (i.e. medications, foods, household products, etc)

Add Allergies

Please list ALL surgeries AND hospitalizations:

Add Surgery/Hospitalization

Please list ALL diagnostic/radiological tests and WHY they were done:

Add Test

Please list ALL medications/supplements you take:

Add Medication

1. Age (if alive)

2. Health(good/bad)

3. Cancer

4. Tuberculosis

5. Diabetes

5. Heart Issues

6. Hypertension

7. Stroke

8. Epilepsy

10. Nervous Breakdown

11. Asthma, hives, hayfever

12. Blood disease

13. Age (at death)

14. Cause of death

Nasal/Sinus Worksheet

Sino-Nasal Outcome Test (SNOT 22)

Please select the number that best describes your symptoms over the past 2 weeks.

Use this scale to describe how bad the problem when it occurs

  • 0 - No Problem
  • 1 - Very mild problem
  • 2 - Mild or slight Problem
  • 3 - Moderate problem
  • 4 - Severe problem
  • 5 - Worst the problem can be

Assignment of Benefits And Release of Information to Medicare

I request the payment of authorized Medicare benefits be made either to me or on my behalf to the physician(s) or supplier listed below for any services provided to me by that physician or supplier. I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid Services and its’ agents, any information needed to determine benefits payable for related services. I understand my signature requests that payment be made and authorizes the release of medical information necessary to pay the claim. If other insurance coverage is listed on my claim form or electronic claim, my signature authorizes the release of information to the insurer shown. In Medicare-assigned cases, the physician or supplier agrees to accept the charge determination of the Medicare carrier as the full charge and the patient is responsible only for the deductible, co-insurance and/or non-covered services. Deductible and co-insurance are based upon the charge determination of the Medicare carrier. This assignment is valid from today’s date and remains in effect until I, the patient, revoke this agreement.

HNA Allergy & Asthma

Sunil Saini, MD

Geeta Venkat, MD

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.

Your information will be encrypted.