BEFORE YOUR VISIT
Forms
Needed For Your First Visit
| No
Show Policy | Financial
Policies |
Participating
Insurances
Hospital
Affliates
• Patients are required
to complete the following forms
before being seen in our office
• Administrative
Data Sheet Adult
(or) Administrative
Data Sheet Dependent
• HIPAA
Written Acknowledgement Form
)
• You can save time by downloading
the appropriate form before your
visit and completing it before
you arrive.
• We are also required
by law to provide you with our
"Notice
of Privacy Practices"
(NPP). This also available at
the offices.
• This
is a requirement as spelled
out in the Health Insurance
Portability and Accountability
Act (HIPAA), 45 CTR Parts 160
and 164 (the "Privacy
Regulation"). Health Care
Providers at Ear, Nose and
Throat, Ltd. have adopted privacy
policies regarding usage of
patients' right to privacy.
•
Please click
on the following link to review
the NPP
• Once you have reviewed
it you can download the "HIPAA
Notice of Privacy Practices
Written Acknowledgement Form" and
fill in the appropriate areas,
sign it and bring that along
with you.
•
Complete the appropriate Data
Sheet when you come for your
first visit.
• If this is a return visit, you will be asked to review your information
for any changes and sign the Update Sheet. This will be scanned into your medical
record.
Forms are
in Adobe Portable Document
Format (PDF).
 Notification
of Privacy Practices Adobe
PDF (126 kb)
HIPAA
Written Acknowledgement Adobe
PDF (73 kb)
Administrative
Data Sheet (Adult) Adobe
PDF (104 kb)
Administrative
Data Sheet (Dependent) Adobe
PDF (110 kb)
Click here
to download the Adobe
PDF free reader.
Any patient who fails to show
up for a scheduled appointment
and does not give sufficient
notification (within 24 hours
of scheduled appointment) will
be designated as No Show.
After two (2) no shows the
doctor will be consulted as
to the future status of the
patient. It may be decided to
remove the patient from the
practice.
No Shows may incur a
fine of $25 for the first
No Show - $50 for the
second No Show (unless the patient
is to be removed from the practice).
Any questions may be addressed
to the Business Manager / (757)
623-0526.
This
Financial Policy is designed
so patients and/or parents/guardians
of Ear, Nose and Throat, Ltd.
understand our position on
payment for services rendered
by the providers.
• All new patients will
be required to fill out an
Ear, Nose and Throat, Ltd.
Patient Information Sheet,
front and back.
•
The back of the form contains
an explanation of financial
expectations for patients and/or
parents/guardians for services
rendered by the clinical providers
at Ear, Nose and Throat, Ltd.
•
The patient will read and sign
the back of the form. The Receptionists
will witness the form with
their signature and date it.
•
The front and back of the form
will be scanned into the Electronic
Medical Records of the patient.
The original is placed in a
locked shredding bin.
•
Patients With Health Insurance: • If a patient
and/or parent/guardian have
health insurance, this contract
is between them and their
insurance carrier. The co-insurance
amounts, and deductibles
that have not been satisfied,
are the responsibility of
the patient, parent/guardian.
Co-payments are expected
at the time services are
rendered.
• Patients with a balance
owed are expected to pay
the balance in full upon
receipt of the invoice. Consideration
will be made for extenuating
circumstance, but only if
the recipient notifies one
of the Patient Account Representatives
first.
• Patients who are
unable to pay their bill
or have
questions are expected to
contact the Patient Account
Representative responsible
for their account before
your payment becomes overdue.
• For self-pay patients:
• A standardized
payment formula will be used
for office visits and procedures
conducted in the office. A
minimum of $150 is expected
prior to seeing the doctor.
A pre established standard
deduction will be applied by
Ear, Nose and Throat, Ltd.
to the office visit / procedure
charge.
• Once the patient’s
visit is concluded, the check
out personnel will review the
Superbill, if there are additional
procedures marked, to include
Audio, the patient will be
informed that additional charges
have been incurred and will
be billed to the patient. It
is not the front desks responsibility
to inform the patient of the
amount, this will be calculated
by the Billing department within
approximately 14 business days
of the visit.
• For patients that
did not have any other procedures
or
Audio, the patient may be eligible
for a refund, but this will
not be confirmed until after
the Superbill has gone through
Billing, in approximately 14
business days.
• When surgery is required,
in most cases, a 50% down payment
is expected at least one week
prior to the elective surgery
date. The remainder of the
payments will be expected within
30 days after the surgery,
unless other payment arrangements
are made.
• For urgent surgeries,
the Patient Account Representative
from Ear, Nose and Throat,
Ltd. will work closely with
the patient to establish a
payment plan.
• For special cosmetic
cases, these will be handled
on a
case-by-case basis and are
discussed between the patient
and the doctor.
• Patient accounts are
considered delinquent if no payment
has been received within 30 days
after the mailing of the second
invoice, unless the patient has
contacted the Patient Account
Representative.
•
These delinquent accounts are
sent to the pre-collections department
where attempts will be made to
collect the monies owed.
•
If after 60 days, no monies have
been received, then the account
is forwarded to a collection
agency
•
A finance charge will added to
the account at that time in the
amount of 15% of the amount owed.
Accounts with a payment plan
will be excluded.
•
The patient is expected to pay
the balance and all reasonable
fees associated with the account
being in pre-collections and
collections.
•
By signing the back of the Patient
Information sheet the patient,
parent/guardian acknowledge that
this form is being signed in
either Norfolk, VA, or Chesapeake,
VA, and that services are being
performed in either Norfolk,
VA, or Chesapeake, VA and should
a suit become necessary to collect
on this account that court filings
will be in either Norfolk, VA
or Chesapeake, VA.
We participate with the following
major insurance carriers: If
you do not see your insurance
company listed please refer
to your provider manual or
contact our billing office
for assistance.
Aetna
Alliance PPO (Mamsi)
Anthem (BCBS, Healthkeepers)
Champ VA
Cigna (VA only)
First Health
Mail Handlers
MDIPA
Medicaid of VA
Medicaid of NC
Medicare and Railroad Medicare
Metro Machine Health Plan
Multi Plan
One Health Plan
Optima
PHCS
Tricare Standard, Prime and Tricare for Life
United Healthcare
Virginia Health Network (VHN, Beech St)
Virginia Premier
We participate with the following
major insurance carriers: If
you do not see your insurance
company listed please refer
to your provider manual or
contact our billing office
for assistance.
Sentara
Norfolk General Hospital
Sentara
Leigh Hospital
The
Children's Hospital of the
King's Daughters
Bon
Secours DePaul Medical Center
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