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.