Patient Information

Dear Patient:

Welcome to our office! Thank you for choosing us as your health care provider. Our practice is devoted to the diagnosis and management (both medical and surgical) of problems affecting the ears, nose and throat. This specialty, otolaryngology, also includes the treatment of allergic problems as well as snoring, sleep apnea, hearing loss and plastic surgery of the nose and face. We practice all facets of this specialty, therefore; do not hesitate to discuss with us any related health problems.

Our office will attempt to provide you with the best possible medical care and service. If for any reason, you are unable to keep your scheduled appointment time, we ask that you call to cancel so that another patient can be accommodated.

You are responsible for payment of your bill today. However, our office is equipped with the latest computer technology, and we are happy to submit your claim to insurance (if you provide this information to us).

You will find our office staff to be very receptive to any problems that you may have and anxious to help you. If there are any ways that we can further assist you, please let us know.
 

Patient Registration

Patient Name  

Gender  
Male    Female      

Marital Status  
Single    Married    Divorced    Legally Separated    Widowed   

Employed  
Full Time    Part Time    Retired    Not      

Student  
Full Time    Part Time   

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Is patient under the age of 18?  
Yes    No   

Do you have healthcare insurance?  
Yes    No   

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How were you referred to us?  
Physician    Internet    Family/Friend    Other   

Medical History

Patient Name  

Please check any of the following conditions that you now have (or have ever had):

Are you currently taking medications or herbal supplements?
Yes    No    

Do you have any medication allergies?
Yes    No

Have you had any previous surgeries?
Yes    No

Are you pregnant?     
Yes    No   

Are you nursing?  
Yes    No   

Completed by  
Patient    Nurse   

Sinus/Allergy/Nasal History

Patient Name  

What symptoms do you experience? (check all that apply)

What have you taken OVER-THE-COUNTER in the past for your symptoms? (check all that apply)

What PRESCRIPTIONS have you taken in the past for your symptoms? (check all that apply)

Allergy Testing (if you have a copy, please bring to appointment)

Did you do allergy desensitization (allergy injections)?  
Yes    No   

Sinus CT (if you have a copy of your images and report, please bring to appointment)

Privacy Notice Acknowledgment

I,   hereby give my consent to Affiliated Ear Nose &Throat Physicians, Ltd. to use or disclose, for the purpose of carrying out treatment, payment, or health care operations, all information contained in the patient record of  

I acknowledge receipt of the physician’s Notice of Privacy Practices. The Notice of Privacy Practice provides detailed information about how the practice may use and disclose my confidential information.

I understand that the physician has reserved a right to change his or her privacy practices that are described in the notice. I also understand that a copy of any revised notice will be provided to me or made available. There is a copy of the new privacy notice in the waiting room and exam rooms for your review.

I understand that this consent is valid until it is revoked by me. I understand that I may revoke this consent at any time by giving written notice of my desire to do so to the physician. I also understand that I will not be able to revoke this consent in cases where the physician has already relied on it to use or disclose my health information. Written revocation of consent must be sent to the physician’s office.

Signature of Patient or Legal Guardian – 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.

 

Leave messages on answering machine  
Yes    No   

Leave message with any other person:  
Yes    No   

HIPAA Authorization:
Other than to myself, I authorize Affiliated Ear, Nose & Throat Physicians to disclose my health information to:

Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This practice creates a medical record of your health information in order to treat you, receive payment for services delivered, and to comply with certain policies and laws. We are also required by law to provide you with this Notice of our legal duties and privacy practices. In addition, the law requires us to ask you to sign an Acknowledgment that you received this Notice.

We are required by federal and state law to maintain the privacy of your medical information. Medical information is also called “protected health information” or “PHI.” We are also required by law to notify you if you are affected by a breach of your unsecured PHI.

This is a list of some of the types of uses and disclosures of PHI that may occur:

Treatment: We obtain health information, or PHI, about you to treat you. Your PHI is used by us and others to treat you. We may also send your PHI to another physician, facility, or counselor to which we refer you for treatment, care, procedures, or testing. We may also use your PHI to contact you to tell you about alternative treatments, or other health-related benefits we offer. If you have a friend or family member involved in your care, we may give them PHI about you.

Payment: We use your PHI to obtain payment for the services that we render. For example, we send PHI to Medicaid, Medicare, or your insurance plan to obtain payment for our services.

Health Care Operations: We use your PHI for our operations. For example, we may use your PHI in determining whether we are giving adequate treatment to our patients. from time-to-time, we may use your PHI to contact you to remind you of an appointment.

Legal Requirements: We may use and disclose your PHI as required or authorized by law. For example, we may use or disclose your PHI for the following reasons:

Public Health: We may disclose your health information to prevent or control disease, injury or disability, to report births and deaths, to report reactions to medicines or medical devices or to report suspected cases of abuse or neglect.

Health Oversight Activities: We may use and disclose your PHI to state agencies and federal government authorities when required to do so. We may use and disclose your health information in order to assist others in determining your eligibility for public benefit programs and to coordinate delivery of those programs. For example, we must give PHI to the Secretary of Health and Human Services in an investigation into our compliance with the federal privacy rule.

Judicial and Administrative Proceedings: We may use and disclose your PHI in judicial and administrative proceedings. Efforts may be made to contact you prior to a disclosure of your PHI to the party seeking the information.

Law Enforcement: We may use and disclose your PHI in order to comply with requests pursuant to a court order, warrant, subpoena, summons, or similar process. We may use and disclose PHI to locate someone who is missing, to identify a crime victim, to report a death, to report criminal activity at our offices, or in an emergency.

Avert a Serious Threat to Health or Safety: We may use or disclose your PHI to stop you or someone else from getting hurt.

Work-Related Injuries: We may use or disclose PHI to an employer if the employer is conducting medical workplace surveillance or to evaluate work-related injuries.

Coroners, Medical Examiners, and Funeral Directors: We may use or disclose PHI to a coroner or medical examiner in some situations. For example, PHI may be needed to identify a deceased person or determine a cause of death. Funeral directors may need PHI to carry out their duties.

Armed Forces: We may use or disclose the PHI of Armed Forces personnel to the military for proper execution of a military mission. We may also use and disclose PHI to the Department of Veterans Affairs to determine eligibility for benefits.

National Security and Intelligence: We may use or disclose PHI to maintain the safety of the President or other protected officials. We may use or disclose PHI for the conduct of national intelligence activities.

Correctional Institutions and Custodial Situations: We may use or disclose PHI to correctional institutions or law enforcement custodians for the safety of individuals at the correctional institution, those that are responsible for transporting inmates, and others.

Research: You will need to sign an Authorization form before we use or disclosure PHI for research purposes except in limited situations. For example, if you want to participate in research or a clinical study, an Authorization form must be signed.

Fundraising: We do not engage in fundraising activities. We do not engage in marketing activities, and need your authorization to do so.

Immunizations: If we obtain and document your verbal or written agreement to do so, we may release proof of immunization to a school where you are a student or prospective student.

Illinois law: Illinois law also has certain requirements that govern the use or disclosure of your PHI. In order for us to release information about mental health treatment, genetic information, your AIDS/HIV status, and alcohol or drug abuse treatment, you will be required to sign an Authorization form unless state law allows us to make the specific type of use or disclosure without your authorization.

Your Rights: You have certain rights under federal and state laws relating to your PHI. Some of these rights are described below:

Restrictions: You have a right to request restrictions on how your PHI is used for purposes of treatment, payment and health care operations. We are not required to accommodate to your request, except as required by law. The practice is required to comply with your request for restrictions on the use or disclosure of your PHI to health plans for payment or health care operations purposes when the practice has been paid out of pocket in full and the practice has been notified of the request for restriction in writing, and the disclosure is not required by law.

Communications: You have a right to receive confidential communications about your PHI. For example, you may request that we only call you at home. If your request is reasonable, it may be accepted.

Inspect and Access: You have a right to inspect your health information. This information includes billing and medical record information. You may not inspect your record in some cases. If your request to inspect your record is denied, we will send you a letter letting you know why and explaining your options.

You may have a paper or electronic copy of your PHI in most situations. If you request a copy of your PHI, we may charge you a fee for making the copies and mailing them to you, if you ask us to mail them.

Amendments of Your Records: If you believe there is an error in your PHI, you have a right to request that we amend your PHI. We are not required to agree with your request to amend.

Accounting of Disclosures: You have a right to receive an accounting of disclosures that we have made of your PHI for purposes other than treatment, payment, and health care operations, or release made pursuant to your authorization.

Copy of Notice: You have a right to obtain a paper copy of this Notice, even if you originally received the Notice electronically. We have also posted this Notice at our offices.

Complaints: If you feel that your privacy rights have been violated, you may file a complaint with us by calling our Privacy Officer at (815-338-4600) we will not retaliate against you for filing a complaint. You may also file a complaint with the Secretary of Health and Human Services in Washington, DC if you feel your privacy rights have been violated.

Authorizations: We are required to obtain your written Authorization when we use or disclose your PHI in ways not described in this Notice or when we use or disclose your PHI as follows: for marketing purposes, for the sale of your PHI, or for uses and disclosures of psychotherapy notes (except certain uses and disclosures for treatment, payment, or health care operations), You may revoke your Authorization at any time in writing, except to the extent that we have already acted on your Authorization.

We are required to abide with terms of the Notice currently in effect; however, we may change this Notice. If we materially change this Notice, you can get a revised Notice on our website or by stopping by our office to pick up a copy. Changes to the Notice are applicable to the health information we already have.

EFFECTIVE DATE: September 23, 2013

Financial Policy

FINANCIAL POLICY: To help us provide the most efficient and reasonable health care services, it is necessary for us to have a financial policy stating our requirements for payment of services provided to patients.

Patients are responsible for the payment of all services provided by Affiliated Ear, Nose and Throat Physicians. You will be asked to pay any co-pay, deductible, or co-insurance that is patient responsibility at the time of your visit. We accept personal checks, Visa, MasterCard, Discover and debit cards. It is our policy to file your insurance as a courtesy to you if we have accurate and complete insurance information. The balance due is still your responsibility if we have not received payment from the insurance carrier within 45 days of the date of service. There will be a $30.00 service fee added to your account for any check returned unpaid from the bank for any reason.

If you do not have any insurance, you will be considered “self-pay” and payment is due IN FULL at the time of service.

If you have insurance, and you have asked us to file a claim for you, we ask that you pay, at the time of service, your co-pay, co-insurance, any deductible not met or any portion which would be your responsibility. If you are covered under an HMO, you are responsible for obtaining all referrals necessary for payment from your primary care physician.

Medicare Beneficiaries – CT scans are performed in our facility. If desired, these CT scans may be performed at: Centegra MMC-Woodstock; Centegra NIMC-McHenry; Mercy-Woodstock; Good Shepherd Hospital-Barrington or Sherman Hospital-Elgin. Addresses available upon request.

Our financial policy is necessary to assure the financial resources needed to maintain vital health care for all our patients, as well as ensure that we will be reimbursed for your care on a timely basis. We welcome the opportunity to discuss any aspect of our financial policy.

• Assignment of Insurance Benefits: I hereby authorize direct payment of benefits to Affiliated ENT Physicians for services rendered.
   
• Authorization for Release of Information: I hereby authorize Affiliated ENT Physicians to release any medical information necessary for the processing of my insurance claim if requested by my insurance company.
   

I have read the Financial Policy and Appointment Policy of Affiliated ENT Physicians and hereby agree to abide by the provisions it sets forth.
 

Consent for Diagnostic Tests/Procedures

Affiliated Ear, Nose & Throat Physicians is pleased you have chosen us for your care. Our physicians feel that a patient presenting to our office with sinus, allergy, throat or hearing complaints requires a thorough examination of that specific area. In some cases, this can only be accomplished by diagnostic tests or procedures, which your physicians may feel are medically necessary. The tests or procedures are separate from the physician’s office consultation and thus have a separate charge. Insurance companies may consider the nasal endoscopy or laryngoscopy a “surgical procedure.” Any of these tests or procedures may be applied to your deductible and/or co-insurance based on your insurance plan benefits.


**For informational purposes only. Document will be signed at scheduled appointment.