Patient Paperwork

Administration:

• Registration Form
• Authorization for Medical Release
• Notice of Privacy Practices
• Nondiscrimination Statement
• Nondiscrimination Statement Multi-Language
• Terms of Service
• Your Right to an Interpreter

Medical:

• Allergy History Form
• Allergy Test Instructions
• Health History Form
• Request Medical Records with ChartFast

Financial:

• Financial Policy

Patient Portal

Insurance Claims and Payment

Payment is due at time of service. For payment details visit our Financial Policy. This includes all copayments, coinsurances and deductibles. Your insurance card must be presented for verification at each visit.

We accept cash, check, Visa, MasterCard, American Express and Discover.

Ear, Nose and Throat Specialists are in-network providers for many plans, including the following:

• Anthem
• Arise Health Plan
• Humana and Humana One
• Network Health Plan
• Common Ground
• United Health Care
• WPS

We encourage you to contact your insurance carrier directly regarding coverage. If your plan is not listed, please contact our office at (920) 969-1768 to discuss your options.

Financial Policy