{"id":115,"date":"2019-05-30T13:19:52","date_gmt":"2019-05-30T17:19:52","guid":{"rendered":"https:\/\/entltd.fm1.dev\/patient-resources\/patient-forms\/"},"modified":"2023-09-25T19:40:12","modified_gmt":"2023-09-25T23:40:12","slug":"patient-forms","status":"publish","type":"page","link":"https:\/\/www.entltd.com\/patient-resources\/patient-forms\/","title":{"rendered":"Patient Forms"},"content":{"rendered":"\n

Your First Visit<\/h2>\n\n\n\n

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<\/strong> below.<\/p>\n\n\n\n

In order to download and view the following files you will need the free Adobe Acrobat Reader<\/a>. If you need to download the reader, click on this link<\/a> and follow the instructions.<\/p>\n\n\n\n\n\n\n\n

Administrative Data Sheet Adult<\/a>Download<\/a><\/div>\n\n\n\n
Administrative Data Sheet Dependent<\/a>Download<\/a><\/div>\n\n\n\n
HIPAA Written Acknowledgement Form<\/a>Download<\/a><\/div>\n\n\n\n
Patient History Form (First time only)<\/a><\/a>Download<\/a><\/div>\n\n\n\n
Review of Symptoms<\/a><\/a>Download<\/a><\/div>\n\n\n\n
Authorization to Release Information<\/a>Download<\/a><\/div>\n\n\n\n

Your Child\u2019s First Visit<\/h2>\n\n\n\n

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.<\/p>\n\n\n\n

Authorization to give consent for medical treatment<\/a>Download<\/a><\/div>\n\n\n\n

HIPAA<\/h2>\n\n\n\n

We are also required by law to provide you with our “Notice of Privacy Practices”<\/strong> (NPP). This also available at the offices.<\/p>\n\n\n\n

This is a requirement as spelled out in the H<\/strong>ealth I<\/strong>nsurance P<\/strong>ortability and A<\/strong>ccountability 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<\/p>\n\n\n\n

Once you have reviewed it you can download the “HIPAA Notice of Privacy Practices Written Acknowledgement Form”<\/strong> and fill in the appropriate areas, sign it and bring that along with you.<\/p>\n\n\n\n

HIPAA Written Acknowledgement Form<\/a>Download<\/a><\/div>\n\n\n\n

Request for Release of Information<\/h2>\n\n\n\n

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 <\/span><\/p>\n\n\n\n

Patient Authorization for Use and Disclosure of Health Care Information<\/a>Download<\/a><\/div>\n\n\n\n

No Show Policy<\/h2>\n\n\n\n

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. <\/p>\n\n\n\n

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.<\/p>\n\n\n\n

Any questions may be addressed to the Business Manager at (757) 623-0526<\/span><\/a>.<\/p>\n","protected":false},"excerpt":{"rendered":"

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