Fillable Kentuckiana Ear, Nose & Throat Patient Information

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Kentuckiana Ear, Nose & Throat Patient Information

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  • 26 check-boxes
  • 166 other fields

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Kentuckiana Ear, Nose & Throat Patient Information
Please Print
Patient Name ___ SS#__
Address __
City ___ State __ Zip ___
Phone # (___) ___________________________ Cell # (____) __________________________________
Date of Birth ________________ Age __________ Martial Status W Sex
Email Address_________________________________________________________________________
Employer __________________________________ Phone # __________________________________
Address______________________________________________________________________________
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Race (Mark Only One) □American Indian or Alaskan Native □Asian □Black or African American
□Native Hawaiian or Other Pacific Islander □Some Other Race □White □Decline to State
Ethnicity (Mark Only One) □Hispanic or Latino □Not Hispanic □Latino □Decline to State
Preferred Language (Mark Only One) □English □Spanish □Other ______________________
**********************************************
Address same as above
Spouse/Responsible Party Full Name _______________________________________________________
Address _______________________________________________________________________________
City _______________________________ State ___________________ Zip ______________________
Phone (____) _____________________ SS# ______________________ DOB ______________________
Employer ____________________________________________ Phone # (____) ____________________
Address _______________________________________________________________________________
Relationship to Patient ___________________________________________________________________
**************************************************
Person to contact in case of emergency (not living with you) ____________________________________
Address _______________________________ City_______________ State __________ Zip ___________
Phone (___) ____________________ Relationship ___________________________________________
********************************************
Primary Insurance ______________________________________________________________________
Primary Insurance Claims Address __________________________________________________________
Subscriber ID # ____________________________________ Group # ______________________________
Effective Date ____________________________________ Is referral needed? ______________________
Policy Holder’s Name ____________________________________________________________________
Policy Holder’s DOB ____________________________ Policy Holder’s SS # ________________________
Policy Holder’s Place of Employment ________________________________________________________
Policy Holder’s Relationship to Patient ______________________________________________________
****************************************************
Secondary Insurance _____________________________________________________________
Secondary Insurance Claims Address ________________________________________________________
Subscriber ID # __________________________________ Group # ________________________________
Effective Date ____________________________________ Is referral needed? ______________________
Policy Holder’s Name ____________________________________________________________________
Policy Holder’s DOB _________________________ Policy Holder’s SS # ___________________________
Policy Holder’s Place of Employment ________________________________________________________
Policy Holder’s Relationship to Patient ______________________________________________________
Male
Widowed
OFFICE POLICY
KENTUCKIANA EAR, NOSE & THROAT, PSC
Your co-payment is due at the time services are rendered. You may pay by check, cash, MasterCard, Visa,
American Express, or Discover Card.
We will file insurance for covered services for all plans with which we participate. If you are covered by
insurance, you will need to be prepared to pay your deductible and copayment amounts at the time of your visit.
Please contact your insurance carrier for your benefit information and whether or not services will be covered in
our office. If your insurance requires a referral you will need to obtain the referral from your primary care
physician prior to your visit in order for us to see you. For scheduled surgery, our billing department will
determine your estimated patient responsibility and request this payment prior to your scheduled surgery.
Any claim filed to secondary insurance, if not paid in 30 days, will become the responsibility of the
patient I guarantor.
You will be asked to complete a registration form at your visit and every new year thereafter. We recognize
the "Responsible Party" to be the parent I legal guardian who typically brings the child(ren) in to see the
doctor - regardless of who the insured might be. If you anticipate a grandparent or someone other than
yourself will EVER bring the child(ren) in, please sign consent for care to be provided in your absence (at the
end of this agreement). We DO NOT bill exes and I or noncustodial parents without a full copy of a court
order indicating such persons' 100% responsibility of medical expenses.
We participate with Medicare and will file your Medicare claims for you. If you have a Medigap secondary
policy, Medicare will automatically submit your secondary insurance for you. If you have a secondary policy
other than Medigap, you will need to provide your secondary insurance information in order for your claim to be
filed. You will need to be prepared to pay all deductible, coinsurance and copay amounts determined by your
insurance and charges for Medicare noncovered services at the time of your visit.
Any balance on your account not paid by insurance within 60 days will become your responsibility and
payment will be due from you. We do all we can to provide pertinent medical information on your claim.
However, we are unable to act as an intermediary between you and your insurance carrier. Please contact
the customer service representative of your insurance plan, if you are dissatisfied with your claim denial and
feel your service should be covered.
Refills: Prescriptions may be refilled during business hours Monday thru Friday only. The patient records are
not available once the office is closed, therefore refills cannot be given on weekends. We may refuse to
refill medications if we have not seen you in six months or if you have missed several appointments.
If you have any question concerning our financial policy, please call our billing department at 894-9753. Our
staff is always pleased to be of service to you.
Signature Date
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signature
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INSURANCE AND BILLING AUTHORIZATION
I understand that I am financially responsible to Kentuckiana Ear, Nose & Throat for any charges incurred for services
performed regardless of insurance coverage.
I understand that Kentuckiana Ear, Nose & Throat will file a claim for my services but that I am responsible for any and
all amounts not covered and not paid by my insurance carrier. If my insurance requires a referral for my office
visit, I
understand that it is my responsibility to obtain this and present it at the time of my visit (if not before).
I hereby authorize Kentuckiana Ear, Nose & Throat to submit a claim to my Insurance Carrier or it’s intermediaries for
all covered services rendered by Kentuckiana Ear, Nose & Throat and direct my insurance carrier or it’s intermediaries
to issue payment check directly to Kentuckiana Ear, Nose & Throat.
Initial ______
Date _____
_
CONSENT FOR CARE AND TREATMENT OF DEPENDENT
I certify
that I am the parent or legal guardian of
Dependent’s Name
I give my consent to the physicians of Kentuckiana Ear, Nose & Throat to examine and render treatment as
appropriate for the above-named patient.
I understand that I am responsible for any balances owed (i.e. co-pays, deductible, co-insurance, etc.).
I also understand that it is my responsibility to furnish this office with current insurance information should there be any
change in my insurance coverage or I will be responsible for any charges incurred.
Initial
of parent or guardian ___________________ Date ___________
Relationship to Patient ___________________________________
MEDICARE AUTHORIZATION
I authorize the physicians of Kentuckiana Ear, Nose & Throat to submit all information necessary to the Federal
Medicare Carrier and my Medigap carrier in order to file a claim for services provided to me.
I understand that Medicare will only pay for services that it deems medically necessary.
I understand that there are also a number of services that Medicare considers noncovered and / or not
medically necessary and that Medicare will not make payment for these services. These include hearing loss,
hearing aids, cosmetic surgery and other services and supplies.
I understand that my physician has reason to believe that Medicare may not cover part or all of the
services rendered. I agree to be financially responsible for and pay for all services for which Medicare does
not pay.
Initial _________________ Date _____________
Minor Office Procedure Notification
At Time of Service
Dear Patient:
Your insurance company requires that we bill the services we provide to you using a coding system
known as CPT (Current Medical Terminology). The codes used to describe some of the services we
provide in our office as part of your evaluation and treatment are found in the “surgery” section of the
CPT codebook. This does not mean we are implying that you are having an operation. This is merely the
way the CPT codebook is organized for ease of use by insurance companies and physicians alike.
According to CPT guidelines, the procedures listed below may be shown on your Explanation of Benefits
(EOB) form from your insurance company (after your visit) as a surgical procedure. As such, your
insurance company may apply a surgical co-payment, deductible or out-of-pocket/co-insurance amount
over and above your regular office visit co-payment as your responsibility. Unfortunately, we do not
know what your specific insurance company will and/or will not cover until after the provided services
are rendered and billed.
We are providing this form to notify you of what you may see on your statement from your insurance
company. Please know that we do correctly perform and document services that we render as required
by the CPT coding guidelines.
Ear Procedures: Debridement of mastoid cavity (CPT 69222)
Removal of impacted cerumen (CPT 69210)
Nasal Procedures: Nasal endoscopy (CPT 31231)
Nasal cautery (CPT 30901)
Throat Procedure: Fiberoptic laryngoscopy (CPT 31575)
If you have any questions regarding this notice, please ask your physician or his medical assistant for
further clarification. Thank you for allowing us to participate in your care.
Sincerely,
______________________________________
Bruce A. Scott, M.D. Patient/Guarantor Signature
Mark A. Severtson, M.D. ______________________________________
Sammy S. Sohi, M.D. Date
Thomas S. Higgins, M.D. ______________________________________
Sean M. Miller, M.D. Acct. No. (Office Use Only)
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signature
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KENTUCKIANA EAR, NOSE & THROAT
PATIENT HEALTH HISTORY
In order for us to obtain a complete medical history, it is important for you to fill out this form in its entirety. It is
important for your doctor to know you have carefully reviewed every area of this form. Please fill out every item and
print clearly. If an item does not apply to you, write n/a in the space. This information will be entered into the computer
and you are welcome to request a copy of the report if you wish.
Patient's Las
t Name
First
MI
Date of Birth:
Sex
□
M
a
le
□
F
e
m
a
le
Name of Primary Care Physician
:
Name of Physician who referred you to us
:
Do you have other family members that see our physicians? _______________________________________
Preferred Pharmacy Name/phone number
Preferred Pharmacy Address (include City/State)
What is your
□
Height
□
Weight
REASON FOR TODAY'S VISIT
:
PLEASE LIST ANY MEDICATIONS YOU ARE CURRENTLY TAKING:
Name of Medication
Dosage
How Often Taken
ARE YOU ALLERGIC TO ANY MEDICATION?
□
Yes
□
No. If yes, please list below:
Name of Medication
Type of Reaction
SURGERIES AND HOSPITALIZATIONS:
Have you ever had any problems with anesthesia (being numbed or put to sleep)?
□
Yes
□
No
If yes, please list type of problems:
List any surgeries you have had (including dates):
Have you ever been hospitalized for non-surgical reasons?
□
Yes
□
No
If yes, list reasons for hospitalizations
Most Recent Diagnostic/Screening Tests:
mark all that apply (you can approximate the date if needed).
Fecal Occult Blood Testing (FOBT) / (month/year)
Sigmoidoscopy - Flexible / (month/year)
Pap Smear / (month/year)
Mammography _/ (month/year)
Immunizations: mark all that apply (you can approximate the date if needed).
Has received this vaccine / (month/year)
Influenza (Flu) Never received this vaccine
Influenza (Flu) Declined vaccine
Pneumonia (PPV) Vaccine given as an adult / (month/year)
Pneumonia (PPV) Revaccination / (month/year)
CURRENT OR MOST RECENT OCCUPATION
:
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Kentuckiana Ear, Nose & Throat Patient Information

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Completed 4 January 2022

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