S. C. E. N. T. A Space Coast Ear Nose & Throat, Associates COMPLETE HEARING & BALANCE SOLUTIONS To All New Patients: You will need to bring the paperwork ALL filled out (front & back) with your driver’s license and insurance cards. If you have had any scans or lab work such as BLOOD WORK, HEARING TEST, MRI, CT or PET CT, please contact the office or facility where you had them done and obtain a copy to bring to your appointment. If it was a scan please bring a CD with images. This information will assist the physicians in your care. If you need to reschedule or cancel your appointment please do so at least 24 hours in advance. ______________________________________________________________________________________________ 1344 S. Apollo Blvd. Melbourne, FL 32901 321-676-2353 S. C. E. N. T. A Space Coast Ear Nose & Throat, Associates PATIENT REGISTRATION COMPLETE HEARING & BALANCE SOLUTIONS Last Name:____________________________ First Name:__________________________ Address:__________________________________________________________________ City:_________________________________ State:_______ Zip Code:______________ Home Phone:__________________________ Cell Phone:__________________________ Social Security:________________________ DOB:_________________ Primary Physician:_____________________ Sex: M / F Physician Phone:_____________________ Pharmacy Name:_______________________ Pharmacy #:________________________ INSURANCE INFORMATION Primary:__________________________ ___ Secondary:__________________________ Ins #:_______________________________ Ins #:______________________________ Group #:_____________________________ Group #:___________________________ _________________________________________________________________________ RESPONSIBLE PARTY INFORMATION – PERSON INSURANCE IS UNDER (Medicaid patients that are minors please fill out parent information) Last Name:____________________________ First Name:__________________________ Social Security:________________________ DOB:___________________ Sex: M /F Address:__________________________________________________________________ City:_________________________________ State:_________ Zip Code:_____________ Home Phone:__________________________ Cell Phone:__________________________ Emergency Contact Name:____________________________________________________ Relation:______________________________ Phone #:____________________________ AUTHORIZATION TO PAY BENEFITS TO PHYSICIAN: I hereby authorize payment directly to the physician of the surgical and/or medical benefits. If any, otherwise payable to me for his/her services as described, realizing I am responsible to pay non-covered services. Signature:___________________________ Date:_________________________________ AUTHORIZATION TO RELEASE INFORMATION: I hereby authorize the Physician to release any information acquired in the course of my treatment necessary to process insurance claims. Signature:___________________________ Date:_________________________________ S. C. E. N. T. A COMPLETE HEARING & BALANCE SOLUTIONS Space Coast Ear Nose & Throat, Associates CONSENT FOR COMMUNICATION AND / OR DISCLOSURE I request that the following alternatives or limitations relating to communication directed to me by my healthcare provider or employee of Space Coast Ear Nose & Throat, Associates. Do we have permission to: Call you at home? YES NO If yes, can we leave the following information on your voicemail? Appointment Information Billing Information Medical Information YES YES YES NO NO NO Call you at work? YES NO If yes, can we leave the following information on your voicemail? Appointment Information Billing Information Medical Information YES YES YES NO NO NO I give my permission to share the following information with the person(s) names below: Do not list Doctor’s names. For minor’s please list parent names. Name:_________________________ ___ Appointment Information Billing Information Medical Information YES YES YES Name:_________________________ ___ Appointment Information Billing Information Medical Information YES YES YES Name:_________________________ ___ Appointment Information Billing Information Medical Information YES YES YES _______________________________ Patient or Guardian Signature Relationship:____________________ NO NO NO Relationship:____________________ NO NO NO Relationship:____________________ NO NO NO __________________________ Date S. C. E. N. T. A Space Coast Ear Nose & Throat, Associates COMPLETE HEARING & BALANCE SOLUTIONS FINANCIAL POLICY We have established the following policies to improve communication regarding appointments, medical records and your financial responsibility at the time of service or prior to any scheduled surgery. If you have any questions, please feel free to ask a staff member. YOUR INSURANCE POLICY: It is the policy of Space Coast Ear Nose & Throat, Associates and Complete Hearing & Balance Solutions to collect any applicable co-payment and/or deductible at the time of service or prior to surgery. Please be aware that your insurance may require a higher copayment for a specialist office visit. At this time, our office is a participating provider for most insurance plans and most of the major insurance networks. If we are not a participating provider for your insurance plan, we will still file an insurance claim as a courtesy. However, you will ultimately be responsible for any fees. If you are enrolled in a (HMO) insurance plan, you must obtain a referral from your primary-care physician (PCP) before your office visit. We will assist you in this process if applicable. Please be aware that without a referral from your PCP, your office visit may have to be rescheduled. Any fees we charge are for our services only. Any services provided outside of our office will be billed separately by that provider. This would include laboratory, CT scans, MRI scans and surgery performed at the hospital or another facility. Please speak directly with those providers regarding their fees. Federal law prohibits our office from writing off any balances due after insurance. Patients who are experiencing financial difficulties should speak to the office manager prior to their office visit. MISSED APPOINTMENTS/LATE CANCELLATIONS: Broken appointments represent a cost to us, to you and to other patients who could have been seen in the time set aside for you. Cancellations are requested 24 hours prior to your appointment for an office visit. We reserve the right to charge $25 for missed or late cancelled appointments and $50 for a missed or late cancelled office procedure and/or surgery. This fee is not covered by your insurance company. Excessive abuse of scheduled appointments may result in discharge from the practice. Our office understands that emergencies do arise, but please call our office to discuss this with a staff member. COPAY/COINSURANCE/DEDUCTIBLES: It is our policy to collect your copay, coinsurance and/or deductible at the time services are rendered. If you are unable to pay at the time of service, we will need to reschedule your appointment. AUDIO & FOLLOW UP APPTS: If you are having a hearing test and following up with a doctor on the same day or different day, your insurance company may charge you two copays because those appointments are separate. NO INSURANCE/SELF PAY: If you do not have health insurance, we do offer medicare rates. You will need to pay the full amount of your visit. PAST DUE ACCOUNTS: Those older than 60 days or those failing to honor agreed-upon payment terms will be sent to a collection agency. Our office will forward your account balance plus any fees charged by the collection agency. Once the collection agency receives your information, your past due debt will be reported on your credit history. Additionally, you will be dismissed from our practice for financial matters and will have to seek healthcare elsewhere. REFUNDS: Overpayments will be refunded upon request to the responsible party within 30 days. Please keep in mind that an overpayment from your insurance company is not a credit to you and cannot be refunded to you. MEDICAL RECORDS: Upon request, we will provide you with copies of your medical records. Please allow 3 business days for these requests. PATIENT CALLS/MESSAGES: The practice maintains an automated attendant with voicemail. We make every effort to answer patient calls as they come in; however, if the staff member you are trying to reach is not available, please leave a message. It is not necessary to leave several messages. Patient calls are handled in order of priority within 48 hours. If you are experiencing an emergency and unable to reach a staff member, please go to the nearest emergency room. YOUR ACCOUNT: You will be mailed a statement on a monthly basis for any balance due. We request that you pay upon receipt of the statement. Should you have any questions concerning your statement, please do not hesitate to call our office and speak to someone in billing. If your balance is not paid we will need to collect the full amount at your next office visit. Your account must be current prior to any scheduled services. For your convenience, our office accepts cash, checks, VISA, MasterCard and American Express. There will be a $25 charge for returned checks. PATIENT DISMISSAL: Failure to observe these policies, demonstration of unacceptable behavior or medical noncompliance can result in dismissal from the practice. I hereby understand and agree to the financial policies of Space Coast Ear Nose & Throat, Associates. __________________________________________ Patient or Guardian Signature ____________________ Date S. C. E. N. T. A Space Coast Ear Nose & Throat, Associates NAME_____________________________________________ DATE___________________________ MEDICAL HISTORY QUESTIONAIRE Are you currently taking any medications? Please include all over the counter medications as well as vitamins and supplements. List all medical conditions you have been diagnosed with or are taking medication to control. Please list any surgeries that you have had and include the year of the surgery. Do you have any allergies to medications? What reaction did you have? Have you been hospitalized overnight? What condition? What year? FOR PEDIATRIC PATIENTS: Is the patient exposed to second hand smoke? ________________________________________________________ Does the patient attend daycare/ school, 3 or 5 days a week? _____________________________________________ Are their immunizations up to date? ________________________________________________________________ Was the child born Full term/ any complications? ______________________________________________________ NAME___________________________________________ DATE________________________________ Is there anyone in your family with any of the following medical conditions? Please include parents, grandparents, siblings and children. High Blood Pressure ___________________________ Cancer___________________________________ High Cholesterol _____________________________ Diabetes __________________________________ Heart Disease________________________________ Allergies__________________________________ Thyroid Disorder _____________________________ Asthma ___________________________________ Bleeding Disorder__________________________ Hearing Loss__________________________________ Mental Illness_______________________________ Stroke ____________________________________ SOCIAL HISTORY What is your marital status? __________________What is your employment status? _______________ Do you smoke? ___________ Have you ever smoked? ________________ Quit date? _______________ How many years did you smoke? ______________ Do you drink alcohol? _____________How many drinks do you have a week? ____________________ Do you drink caffeine? _____________How many drinks do you have a day? _____________________ (Please include soda, tea and coffee). How many siblings do you have? __________________________________________________________________ Do you have any children? _______________________________________________________________________ CURRENT SYMPTOMS What is the reason for today’s visit? ________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ How long have you been experiencing your symptoms? _________________________________________________ PLEASE CHECK IF YOU ARE EXPERIENCING THE FOLLOWING SYMPTOMS: Ringing in ear Fullness in ear Ear pain Infection in ear Sinus infection Post nasal drip Cough Snoring Allergies Cold symptoms Sore throat Difficulty swallowing Vertigo Light headedness Hearing loss Hoarseness Thank you for your patience and assistance in filling out the questionnaire.