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Date _________   Doctor You're Seeing Today __________________________   SS# ____________
Patient Name______________________________________________________  Age ____________
                               Last                                        First                                            Middle
Address __________________________________________________________ Apt. # ___________
City _______________________________________________ State_________ Zip_______________
Phone # (___)_________________ Cell Phone # _______________  Pager # ___________________
 
Date of Birth _____ / _____ / _____  Marital Status (circle one)    M   S   D   W            Sex    M     F
Employer_________________________________________________ Phone # (____)_____________
Address ___________________________________________________________________________

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Spouse / Responsible Party Full Name __________________________________________________
Address ______________________________________________________ Phone #______________
City ___________________________________ State ____ Zip _______ Date of Birth ___ / ___ / ___
S.S. #___________________________ Relation to Patient __________________________________
Employer__________________________________________________ Phone # _________________
Address ___________________________________________________________________________

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Person to contact in case of emergency (not living with you)_________________________________
Address ___________________________________ City____________________ State __________
Phone (day) __________________ Relationship __________________________________________

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Primary Insurance __________________________________________________________________
Policy Holder's Name & Address ______________________________________________________
Place of Employment _______________________________________________________________
Subscriber ID # ___________________________________ Group No. ________________________
Relationship to Patient ____________________________________ Effective Date ______________
Insured's Date of Birth ____ / ____ / ____  Is referral needed? _______________________________

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Secondary Insurance _______________________________________________________________
Policy Holder's Name & Address _____________________________________________________
Place of Employment _______________________________________________________________
Subscriber ID # __________________________________ Group No. ________________________
Relationship to Patient ____________________________________ Effective Date _____________
Insured's Date of Birth ____ / ____ / ____  Is referral needed? ______________________________
Did your physician ask you to see an ENT doctor? ____ yes  ____ no 
If yes, Name of your Physician _____________________ Primary Care Doctor __________________
Signature________________________________________________ Date ___ / ___ / ___
 
______________________________ Office Use Only _______________________________
| Signature________________________________________________ Date ___ / ___ / ___  |
| Signature________________________________________________ Date ___ / ___ / ___  |
|___________________________________________________________________________|

PLEASE Continue with Page 2  (Authorization Forms)

 

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.

  
Signature ________________________________________________________ Date __________
     

CONSENT FOR CARE AND TREATMENT OF DEPENDENT

   
I certify that I am the parent or legal guardian of _______________________________________
                                                                                                                 Dependent's Name
Of _____________________________________________________________________________
                                                                         Address
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 (ie. 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.
  
Signature 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.

 
Signature of Patient ______________________________________________ Date___________