RESPONSIBILITY FOR PAYMENT OF MEDICAL SERVICES
I understand that Triangle ENT & Allergy will file my insurance as a courtesy. However, I am ultimately responsible for all medical fees relating to my care should my insurance deny for reasons such as: authorization, deductible or noncovered service. I understand that I will be responsible for my bill.
I hereby authorize my insurance benefits to be paid directly to Triangle ENT & Allergy. I also authorize Triangle ENT & Allergy to release information acquired in the course of my examination to my insurance company and/or their representatives.
If you are unable to keep an appointment, please give our office 24 hours notice. This courtesy of cancelling 24 hours in advance will allow another patient the opportunity to use that appointment time. A missed/no show appointment may result in a minimum $25.00 charge to you.
Patient Signature – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.