Patient Registration Form

How did you hear about Texas Ear and Vestibular Institute?

Provider Referral

Friend

Other

If Other, please specify:

Today's Date:

Patient Information

Name:

Last Name:

First Name:

Middle Initial:

Date of Birth:

Age:

Sex:

Height

Weight

Marital Status:

Married Single Widowed Divorced

Address:

City:

State:

Zip:

Email:

Social Security Number:

Home No.:

Business No.:

Cell No.:

Primary Care Physician:

Primary Care Physician No.:

Referring Physician:

Referring Physician No.:

INSURANCE INFORMATION

Primary Medical Insurance

Primary Insurance Company:

Policy Holder:

Policy Holder DOB:

Relationship:

Policy No.:

Group No.:

Secondary Medical Insurance

Secondary Insurance Company:

Policy Holder:

Policy Holder DOB:

Relationship:

Policy No.:

Group No.:

GUARANTOR OR RESPONSIBLE PARTY (IF NOT INSURED)

Same as patient information (If different, please complete section below)

Name:

Date of Birth:

Relationship:

Address:

City:

State:

Zip:

Please select which phone number should we primarily call to:

Home Phone Number Business Phone Number Cell Phone Number

Home Number:

Business Number:

Cell Number:

Employer:

Employer No.:

Employer Address:

City:

State:

Zip:

EMERGENCY NOTIFICATION

Contact Person:

Relationship to Patient:

Home No.:

Work No.:

PREFERRED PHARMACY

Name of Pharmacy:

Phone Number:

Address:

City:

State:

Zip:

PATIENT CONTACT PREFERENCES

Text Message

Voice message with our call back number only

Detailed voice message

Please do not leave messages left by text or voicemail

TEVI POLICES AND CONSENT TO TRE

Missed Appointments: Your appointment time is set aside especially for you. Resources are assigned for each individual patient. We ask that for the courtesy to the Doctor and to other patients that you keep your scheduled appointments.

If you must change or miss an appointment, we require a 24-hour notice. Failure to provide a 24-hour notice to cancel your scheduled appointment will result in a “no show” fee of $50.00 for office visits with Dr. Senchak or a $150 fee for specialty testing and procedures. A no-show fee must be paid prior to being seen at your next visit. Please note that insurance companies do not pay for no-show fees and therefore will not be billed for that charge.

Consent of Treatment: I authorize the staff at Texas Ear and Vestibular Institute to provide any diagnostic tests and examination indicated for treatment.

Disability or Insurance Forms: There will be a charge of $50 for the completion of medical forms. Payment is due at the time that you pick up the forms. Please allow 7-10 days for the completion of these forms.

Medication Policy Consent: I authorize Texas Ear and Vestibular Institute to obtain a medication history and/or list of current medications via my pharmacy for my medical records.

FINANCIAL RESPONSIBILITY AGREEMENT

I hereby assign, transfer, and set over to Texas Ear and Vestibular Institute all of my rights, title, and interest to my medical reimbursement benefits under my insurance policy. All deductibles and copays are due at the time services are rendered and will be collected based on the information provided by your insurance company. I understand that charges not covered by my insurance company or my secondary insurance if applicable, as well as any applicable co-payments, coinsurance, and deductibles are my responsibility. If your insurance is with an HMO or other managed care program, Texas Ear and Vestibular will bill them only if you present an appropriate authorization form. If you do not have an appropriate authorization form for each visit, you will be responsible for all charges during that visit. If your insurance company has not paid your account in 90 days, the balance may be transferred to you for payment.

I understand that if I default on payment for services, my account may be transferred to an independent collection agency, designated as credit risk and payment for services will be required at the time of registration for all future visits. I have read the financial policy as above. I understand and agree to above financial policy.

We currently accept cash, Visa, Mastercard, Discover, American Express and Care Credit. Unfortunately, we are not accepting checks currently. If you have any questions regarding your bill, please contact our billing department at 469-625-2879.

AUTHORIZATION TO RELEASE INFORMATION

I hereby authorize Texas Ear and Vestibular Institute to (1) release any information necessary to insurance carriers regarding my illness and treatments; (2) process insurance claims generated during examination or treatment.

I have requested medical services from Texas Ear and Vestibular Institute. On behalf of myself and/or my dependents, and understand that by making this request, I become fully financially responsible for all charges incurred in the course of the treatment authorized.

Texas Ear and Vestibular Institute MAY NOT discuss my healthcare and may not discuss and/or make financial arrangements with anyone, except as permitted by HIPAA and other applicable laws

Texas Ear and Vestibular Institute MAY discuss my healthcare and MAY discuss and/or make financial arrangements with only the following individual immediate family members listed below:

Add new row

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I understand that I have rights as a patient of Texas Ear and Vestibular Institute. I acknowledge that, upon request, I can request a copy of the Patient Rights and Responsibilities practices.

With my consent, Texas Ear and Vestibular Institute may use and disclose of my protected health information protected under Health Insurance Portability and Accountability Act of 1996 for treatment, billing/payment, and health care operations.

I understand that I have the right to request, now and in the future, how protected health information is used or disclosed to carry out treatment, payment, and health care operations.

I understand that I have the right to revoke this authorization, in writing, at any time by sending such written notification to the Practice’s Privacy Officer. I understand Texas Ear and Vestibular Institute may refuse me further service if I revoke the consent.

I, have read or have had someone read to me the Texas Ear and Vestibular Institute Policies and Procedures listed above. By signing below and initialing the spaces above I am giving my consent to treat, comply and assign my visits to my insurance company or the guarantor.

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.

Patient's Signature

Date:

Briefly describe what brings you in for an appointment

For Cancer, please specify type.

For Other, please specify.

Please list surgeries you have had, along with year if known

NONE – I have never had surgery

Add another list of surgery

Other Ear Disorder

Other Nose Disorder

Other Throat Disorder

Other

Please list all medication that you take, along with dose (you may provide a separate list if you have one):

NONE – I currently do not take any daily medications

Add another medication

Are you allergic to any medications?

Yes No

If allergic to medications, list them here.

Do you smoke or use nicotine products?

Yes No

If yes, please list type and how often:

Do you drink alcohol?

Yes No

If yes, please list how often:

Do you drink caffeine?

Yes No

If yes, please list how much:

Did you have a flu shot during the most recent flu season?

Yes No

Patients 65 years old and over ONLY:

Have you had you pneumonia vaccine on or after 60th birthday?

Yes No

Do you have a living will?

Yes No

Do you have a Do Not Resuscitate (DNR)?

Yes No

What is your occupation?

Please select:

Full-Time Part-Time Self-Employed Student Retired

Family History – please list any conditions that run in your family:

ENT conditions

Relative

Other conditions

Relative

Other Alert You Want Us to Know: Please specify.

Your information will be encrypted.