I certify this information is true and correct to the best of my knowledge. I will notify you of any changes in the above information. I authorize the release of any medical information necessary to process an insurance claim and request that payment of benefits be made to the physician unless my account has been paid in full. I hereby give lifetime authorization for payment of insurance benefits to be made directly to Lawrence Otolaryngology Associates, LLC and any assisting physicians for services rendered. I understand that I am financially responsible for all charges whether or not they are covered by insurance. I acknowledge financial responsibility for balance due and, in the event of default, agree to pay all collection costs. I hereby authorize this healthcare provider to release all information necessary to secure the payment of benefits and agree a photocopy of this agreement shall be valid as the original. I understand that no guarantees have been made to me regarding the outcome of this care.

I acknowledge I have been offered the LOA Notice of Privacy Practices. I understand that Lawrence Otolaryngology Associates, LLC has made every effort to ensure the privacy of our internet system but cannot guarantee that internet communications are completely confidential. I acknowledge LOA will use the minimum necessary information needed when communicating with me indirectly. I understand that I may revoke or modify this communication waiver at any time. I understand that I may revoke my consent to disclose health information at any time in writing. Any revocation or change will not apply to past communications. I understand this authorization will remain in effect for one year from the date signed unless I specify a date here: I understand courtesy appointment reminder calls, text messages or emails and other important communication may be placed using a pre-recorded message and consent to receiving such communication.

During your office visit your provider may determine that additional procedures must be performed in addition to the specialty examination of the head and neck area to provide appropriate medical care. These procedures provide valuable clinical information when there may be a condition or disease in the ear, nose or throat that is not adequately visualized on routine exam.

Following insurance guidelines, these procedures must be billed separately from the office visit. Most of these procedures are considered to be “covered” procedures by most insurance plans, but they could result in increased out of pocket expense for you as well depending on your individual insurance coverage. Depending on your deductible, part of the allowable fee for these services may be your responsibility. This may be in addition to your copay. There are many such procedures, but some of the most common include:

• Nasal endoscopy (A small scope inserted in the nose to examine the nose and sinuses.)
• Fiberoptic laryngoscopy (A special scope is used to examine the voice box.)
• Cerumen cleaning (cleaning of wax from ears)
• Audiograms (special testing of hearing)
• Laryngeal stroboscopy (a technical instrument is used to provide examination of the voice box and surrounding structures)

Nasal Endoscopy Information: During your visit your provider may want to perform a nasal endoscopy so structures in the nose, mouth and throat can be directly observed. This allows your doctor to:

• Obtain drainage for culture or specimens/ biopsy for pathology evaluation
• Evaluate previous surgery, scar tissue, openings, masses, polyps or causes of blockage
• Remove old blood, foreign material, packing, scabs/scar tissue/blockage

Please note that insurance companies consider diagnostic endoscopy an in-office surgical procedure so often your explanation of benefits will show a “surgical procedure” charge. If you have the Federal BCBS “Basic” plan you will have a 150.00 co-pay for any procedures such as nasal endoscopy, fiberoptic laryngoscopy, laryngeal stroboscopy, etc., which will be inclusive of your office visit copay.

This form is to keep our patients as informed as possible due to medical billing being highly regulated and complicated. If you have any questions about testing that the physician is recommending or if you have any concerns about payment for these procedures, we are happy to help. If you have questions about your coverage we encourage you to call your insurance company to see if the items above will be covered and if there will be any out of pocket amount due to you.

Quality care for our patients is our priority. Please take a few minutes to review our no-show policy.

We understand that sometimes a patient is unable to attend a scheduled appointment due to unforeseen circumstances; however, in order to build a trusting relationship between you and your provider it is important that appointments are kept and your care is consistent. We require a 24-hour notice in the event of a cancellation. When a patient does not show for an appointment, three people are affected: the patient because they do not receive treatment; the provider who now has a space in their schedule since the time was reserved for that patient; and another patient who could have been scheduled for treatment if there had been adequate notice. As a courtesy, you will receive an appointment reminder via phone/text/email two (2) business days ahead of your appointment.

Should you fail to come to an appointment and/or do not give proper notice, your visit will be counted as a “no show”. After two (2) no show visits, you may receive a warning letter. After three (3) no show visits, our office reserves the right to decline rescheduling. We will then make a recommendation of alternative providers you may establish care with and will forward your records to the provider of your choice. Please be aware that any no show appointments occurring prior to the signature of this document may count towards your limit.

Please note: We require a 48-hour cancellation notice for patients who are scheduled for a procedure or surgery. A 50% deposit paid toward the procedure or surgery is non-refundable if cancelled without proper notice.

Thank you for choosing our practice! Our objective is to provide you with the highest quality health care in the most cost-effective manner. We recognize the importance of having a clear financial policy for everyone's benefit, though we also understand that insurance can be confusing. Our goal is to prevent any misunderstandings or concerns regarding financial matters so that we can dedicate our efforts to delivering excellent healthcare services to our patients. We will gladly do our best to answer any questions relating to your insurance.

Insurance: Health Insurance cards must be given to the Receptionist at time of service. If you do not have a physical card, you will need to bring in a copy of your card. We participate in most insurance plans and will fill insurance claims on your behalf. Each plan has different benefits and financial obligations; knowing your insurance benefits is your responsibility. Remember that your insurance contract is between you and your insurer. Not all insurance policies cover all services. If your insurance company pays only part of your bill or rejects your claim, you are financially responsible for the balance and are to pay it upon receipt of your statement. If you are insured by a plan we are contracted with but don’t have an up-to-date insurance card, $100 is due for each visit until you can verify your coverage. Please contact your insurance company with any questions you may have regarding your coverage. It is your responsibility to furnish our office with current, accurate information at the time services are rendered and/or notify us in a timely manner of any changes in coverage which may affect the payment of services already rendered.

• Non-covered services. Please be aware that some of the services you receive may be non-covered or not considered reasonable by Medicare or other insurers. Some insurance companies arbitrarily select certain services they will not cover (i.e., x-rays, labs, hearing tests, Epley maneuver, elective procedures, and pre-existing conditions). You will be responsible for the full charges of these services.
• Co-Pay, Co-Insurance and Deductibles: Payment is expected at time of service for co-pays, co-insurance and deductibles that have not been met, as well as any previous balances due. You can locate your co-pay on your insurance card or call your insurance company to find out what your co-pay, co-insurance and deductible for a specialist will be. Co-pays, co-insurance and deductibles are dictated by your insurance plan and must be paid at the time of your appointment.
• High Deductible Health Plan (HDHP): is a health insurance plan that has a high minimum deductible, which does not cover the initial costs or all of the costs of medical expenses. The deductible requires the patient to pay the first portion of a medical expense before the insurance coverage kicks in. Patients that have a high deductible health plan of $1000.00 or more will need to be prepared to pay for their office visit and any testing done during their visit before they leave the office. You may visit with our billing office about payment plans if needed.
• Insurance Authorizations: If your visit requires authorization, it is your responsibility to have your PCP send an authorization request to your insurance company prior to your appointment. If the authorization is not obtained, the appointment will be cancelled or you will be responsible for the full cost of the visit.

Self-Pay Patients: Self pay patients are patients that have no insurance, do not have a copy of their insurance card with them at the time of service or have an insurance that we are not in network with. Self pay patients are required to pay for their visits at the time of service. Patients are required to pay a deposit of $100.00 upon checking in and pay the remaining difference, if applicable, after their visit with the provider.

College Students: if you have United Health Care student insurance you may have some "policy exclusions" depending on what you are coming into the office for. Please call your insurance company to find out if your visit will be covered.

Surgery and Procedures: Our office will verify insurance eligibility will estimate out of pocket costs for scheduled surgeries and procedures. Please note this is only an estimate based on the information your insurance company provides to us at the time of verification. You may owe more or less once insurance processes your claim. Not all pre-op or post-op appointments are included in this estimate. We encourage patients to also verify their own benefits. Our clinic will obtain the necessary authorizations prior to surgery; however, prior authorization is not guarantee of payment. You are responsible for all charges not paid by your insurance company.

Social Security Numbers: We are required to have the patient's SSN number in order to schedule any surgeries or procedures at LMH, LSC or AdventHealth Ottawa. Not having this information will delay the scheduling process.

Patient balances and payment arrangements: Patients who are unable to pay in full at the end of their visit will need to talk with our billing department for payment arrangements. Balances that are billed to the patient via payment arrangements are expected to be paid in full within 30 days of the mailed statement. Unpaid accounts may be sent to an outside collection service if financial obligations are not met.

Children and Adolescents: We will not see your child when brought in by someone other than a mother or father unless the adult bringing your child in has a written note signed by you authorizing treatment and financial responsibility. Guardians must bring in guardianship paperwork at first appointment to be scanned into your child’s chart.

Divorce decrees: This office is not a party to your divorce decree. Adult patients are responsible for their bill at the time of service. The responsibility for minors rests with the accompanying adult. I have read, understand, and agree to the above financial policy. I understand that charges not covered by my insurance company, as well as applicable co-pays, co-insurance and deductibles are my responsibility.