Please arrive at least 15 minutes prior to your scheduled appointment time and bring all insurance cards and a picture ID to your appointment.

Transcription

1 Enclosed, you will find new patient registration forms. Please complete ALL forms and return them to our office (i.e. mail, fax, , drop off) PRIOR to your scheduled appointment. Please also complete your medical history on our patient portal which can be accessed by going to our website and clicking on the Patient Portal tab. Please read the instructions before going to the portal. If you have not received a user name from us please call Please arrive at least 15 minutes prior to your scheduled appointment time and bring all insurance cards and a picture ID to your appointment. **If you have any previous CT scans, MRI/MRA scans, lab tests, medical records relating to the current problem, it is VERY IMPORTANT to bring those discs AND reports to your appointment.** CO-PAYMENT/CO-INSURANCE/DEDUCTIBLE IS DUE AT THE TIME OF YOUR OFFICE VISIT. We accept: Cash, Personal Checks, Visa, Mastercard, Amex, Discover. PLEASE REVIEW BILLING POLICY FOR LIST OF INSURANCE COMPANIES WITH WHICH WE ARE IN NETWORK. Please notify us at least 24 hours in advance if you are unable to keep your appointment. No-shows will be subject to a $35 cancellation fee. OFFICE LOCATIONS: 23 Main Street, Suite 201: We are 1/10 th mile from Hospital Center Blvd, in the Palmetto Office Suites. It is a tan 3 story building between Emeritus at Hawthorne Inn and J. Banks Design. Our office is on the second floor, Suite 201. **GPS - YOU MUST INPUT 23 NORTH MAIN STREET FOR OUR STREET ADDRESS OR YOUR GPS WILL SEND YOU TO THE OPPOSITE END OF MAIN STREET.** From Bluffton: Take 278 to the island. STAY ON 278 BUSINESS DO NOT TAKE THE CROSS ISLAND EXPRESSWAY / TOLL ROAD. Approximately 6 miles from bridge turn LEFT at 6 th traffic light (Hilton Head Plantation/Indigo Run). Get into right lane. Take FIRST RIGHT off of circle onto Main Street. We are approx. ½ mile from the circle, on the right. If you reach Hospital Center Blvd, you have gone too far. From south end of island: RIGHT on Beach City Road, LEFT on Hospital Center Boulevard, LEFT on Main Street. Building is on the left. Cross Island Parkway: - take WM HILTON PKWY/US 278 E/GUM TREE RD. exit, turn right onto Wm. Hilton Pkwy, make a LEFT at 3 rd traffic light (Hilton Head Plantation/Indigo Run). Get into right lane. Take FIRST RIGHT off of circle onto Main Street. We are approx. ½ mile from the circle, on the right. If you reach Hospital Center Blvd, you have gone too far. 10 Arley Way, #101, Bluffton, SC We are located in Westbury Business Park on Arley Way directly across from First South Bank From Sun City: Turn RIGHT onto Buck Island Road, take the first LEFT onto Arley Way, #10 is the 2nd right. From Hilton Head: Turn LEFT onto Buck Island Road, take the first LEFT onto Arley Way, #10 is the 2 nd right. Page 1

2 Patient s Name: Street Address: City /State/ Zip Code: address: Preferred Language Social Security # of Birth Primary Phone w/area Code & Type (Home, Cell, Work, etc) : Secondary Phone w/area Code & Type (Home, Cell, Work, etc) : Preferred Contact Method: Text Phone May we leave a detailed message: yes no Gender: Primary Race: Hispanic or Latino: yes no Marital Status: Married Single Widowed Divorced Legally Separated Domestic partner Employment Status: Employed Disabled Retired Part-time Student Unemployed Other Emergency Contact Name:_ Relationship: Phone: Responsible Party: Relationship: Self Spouse Parent Other Responsible Party s of Birth: SSN: Responsible Party s Adress (if different than patient s)_ Primary Care Physician Referring Physician: Pharmacy Name & Street: How did you hear about us? Referral Dr Other patient Internet Search Other INSURANCE INFORMATION Please give ALL cards to reception upon check in Policy Holder s Name (if different than patient): Policy Holder s of Birth: SSN: Patient Relationship to policy holder: Spouse Child Domestic partner Other I hereby authorize the payment of medical benefits to Hilton Head ENT & Sinus Center for services rendered. I understand that I am financially responsible for any services not covered by my insurance carrier. I further agree to pay all collection costs, attorney fees, and other expenses that may be incurred to enforce the collection of any amounts outstanding. I hereby authorize Hilton Head ENT & Sinus Center to release any medical information necessary to complete and process my insurance claims. Self Pay I currently do not have health insurance coverage. Therefore, I understand that all charges must be paid on the date of service. Page 2

3 BILLING POLICY The following sets forth the general billing policy of Hilton Head ENT & Sinus Center ( the clinic ). Please review this information and sign where indicated. Below are the insurance companies/networks with which we currently participate (IN NETWORK). We will be happy to file the insurance for you, however, IF YOUR INSURANCE COMPANY IS NOT ON THIS LIST, YOU ARE RESPONSIBLE FOR CONTACTING THEM REGARDING REIMBURSEMENT for your visit. In this case you will be required to pay for your visit in full unless prior arrangements have been made. MEDICARE BLUE CROSS/BLUE SHIELD (INCLUDING Health Insurance Exchange plans) BLUE CHOICE requires referral COVENTRY NATIONAL MEDCOST MEMORIAL HEALTH PARTNERS SELECT HEALTH OF SC AGES 0-18 ONLY ADVICARE MULTIPLAN/PHCS (check w/ your insurance co. to be sure you have access to the network in this area.) TRICARE WE ARE AN APPROVED TRICARE PROVIDER, BUT WE ARE NOT IN-NETWORK, so some things will cost more than a network provider based on tricare allowables. TRICARE PRIME same as tricare MUST HAVE AN ELECTRONIC REFERRAL / AUTHORIZATION OBTAINED FROM TRICARE BY YOUR PRIMARY CARE DOCTOR AND FORWARDED TO US UNITED HEALTHCARE (EXCLUDING Navigate & Core Networks) I understand that it is my responsibility to provide the clinic with current, accurate billing information at the time of check in and to notify the clinic of any changes in this information. I understand that I am responsible for payment of my account at the time of service for deductibles, non-covered services, medically unnecessary services, copayments and insurance balances. It is my responsibility to know my specialist co-pay (which can be different than my Primary Care co-payment). I understand that this is a contractual agreement that I have with my health plan and that the clinic also has a contractual agreement with my health plan to collect co-pays at the time of service, and the clinic is required to report to the carrier any enrollees failing to pay the co-pay. I understand that the clinic will attempt to obtain the necessary prior authorizations prior to rendering treatment. I further understand that prior authorization is not a guarantee of payment, and that I am responsible for any bills not paid by my insurance carrier. I understand that if I present an insufficient funds check (NSF check) for payment on my account that I will be charged a $35 NSF fee. I further understand that to rectify my account, I will be required to pay with cash, a money order, cashier s check, or credit card. I understand that there may be a small fee to copy and mail medical records. I understand it is the policy to collect the deductible and/or coinsurance prior to scheduling my elective surgery. I further understand that THE FEE I AM QUOTED IS AN ESTIMATE based on 1) anticipated surgery to be performed and 2) current information provided to clinic by my insurance carrier. Initials Please be aware that if a biopsy is required at your visit, you will receive a separate bill for this service. The specimen is sent to a pathology lab, where a physician (pathologist) interprets the tissue. This physician will bill you directly for this service. If your insurance requires us to use a specific lab, you must notify us in advance of your visit and we will do our best to accommodate your needs. If you have any problems with your bill from the pathologist, please call our office and we will be happy to help you resolve the matter. I understand that I will be billed for any amounts due by me (co-payments/coinsurance amounts/ deductibles) and that I have a financial responsibility to pay these amounts. I understand that I will be provided with two (2) statements for any balance due after insurance payment. I further understand that if I have not made payment after the second statement is mailed, the account may be sent to an outside collection service. I also understand that I will be responsible for any collection, interest or legal expenses associated with the collection efforts. My signature below confirms that I have read these billing policies and my financial obligation as pertains to Hilton Head ENT & Sinus Center. Page 3

4 HIPAA CONSENT FORM Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing your rights under the law. You have the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office. You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment, or health care operations. By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The patient understands that: Protected health information may be disclosed or used for treatment, payment, or health care operations The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review this Notice The Practice reserves the right to change the Notice of Privacy Practices as directed by HIPAA The patient has the right to restrict the uses of their information and Practice may agree as covered by law The patient may revoke this Consent in writing at any time and all future disclosures will then cease The Practice may condition receipt of treatment upon the execution of this Consent. This Consent was signed by: Printed Name Patient or Representative Signature Relationship to Patient (if other than patient): Marketing Authorization: We may use your protected health information to contact you with information about treatment alternatives that may be of interest to you. We may disclose your protected health information to a business associate to assist us in these activities. Unless the information is provided to you by a general newsletter or in person or is for products or services of nominal value, you may opt out of receiving such information by initialing below: Please do not provide my protected health information to a business associate without my specific written consent Page 4

5 AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION TO THIRD PARTY (Complete this form if you would like for Hilton Head ENT & Sinus Center to disclose certain protected health information to family members/caregivers) I,, authorize Hilton Head ENT & Sinus Center to use and/or disclose certain protected health information (PHI) as described herein. I understand that, if the person(s) or organization(s) that I authorize to receive my protected health information may not be subject to federal and state health information privacy laws, subsequent disclosure by such person(s) or organization(s) may not be protected by those laws. I authorize the following person (s) and/or organization(s) to receive my PHI, as disclosed by the person(s) and/or organizations(s) above. Name Relationship Name Relationship Name Relationship Specific description of PHI that I authorize for disclosure at the request of the above individuals: Complete medical records (OR INITIAL specific s below if you do not want the complete record released) Diagnostic and Treatment Summaries Operative Reports Radiology Reports & Images Lab Results Pathology Reports Allergy Records Alcohol/Drug Treatment HIV Related Info & test results Mental Health Info This authorization will expire on (date, event, or indefinite): I have the right to revoke this authorization in writing except to the extent that Hilton Head ENT & Sinus Center has acted in reliance upon this authorization. My written revocation must be submitted to Hilton Head ENT & Sinus Center Compliance Officer,. I further understand that my eligibility for health benefits, my enrollment in a health plan, and my treatment will not be affected by whether or not I sign this authorization. I have had the opportunity to read and consider the contents of this authorization. I confirm that the contents are consistent with my direction. Patient s Name Signature of Patient or Legal Guardian of Birth Relationship to Patient (If other than patient) Page 5