Your First Visit
Take a moment and look over the forms we require for your visit. At your first visit, and yearly after that, you will complete the appropriate Administrative Data Sheet below.
In order to download and view the following files you will need the free Adobe Acrobat Reader. If you need to download the reader, click on this link and follow the instructions.
Your Child’s First Visit
It is highly recommended that you bring your child in on their first visit to make sure the correct paper work has been completed. On subsequent visits, If you plan to have someone else bring your child, you will need to fill out the following 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.
Request for Release of Information
If you need for Ear, Nose and Throat, Ltd. to release information in your electronic medical record to another health care provider, please download the below form and fill it in and either bring it one of our offices or fax it to our secure fax number
No Show Policy
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 a no show. All no show patients will follow the same policy.
If a subsequent appointment is requested after a no show, it must be secured with a $50 down payment. This down payment is applied to co-pay, deductible/co-insurance or visit after all claims have processed with insurance, or forfeited upon no show. Credits will be used to offset balances and/or refunded to patient. Absolutely no same day appointments.
Any questions may be addressed to the Business Manager at (757) 623-0526.