ENTZ02 Patient Forms

The ENT Center of Central Georgia
Central Georgia Head & Neck Surgery Center
The Allergy Center
Georgia Hearing Institute

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Name*

First NameMiddle NameLast Name

Preferred Name

Date of Birth*

Date

Pharmacy

Sex*

MaleFemale

Social Security Number *

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Marital Status

MarriedSingleWidowedDivorced

Home Phone Number

Please enter a valid phone number.

Work Phone Number

Please enter a valid phone number.

Cell Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Employer *

Occupation

Employer's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Guarantor Information

Name

First NameMiddle NameLast Name

Social Security Number

Date of Birth

Date

Employer

Work Phone Number

Please enter a valid phone number.

Cell Phone Number

Please enter a valid phone number.

Emergency Notification

Name*

First NameLast Name

Relationship*

Home Phone Number

Please enter a valid phone number.

Work Phone Number

Please enter a valid phone number.

Cell Phone Number*

Please enter a valid phone number.

Insurance

Primary Insurance Company (if you do not have insurance, type none)*

Policy Holder's DOB (if you do not have insurance, type your birthday)*

Date

Policy Holder's Name (if you do not have insurance, type none)*

First NameLast Name

Social Security Number (if you do not have insurance, type none) *

Policy Number (if you do not have insurance, type none)*

Group Number (if you do not have insurance, type none) *

Do you have secondary insurance?

YesNo

Secondary Insurance Company

Policy Holder's DOB

Date

Policy Holder's Name

First NameLast Name

Social Security Number

Policy Number

Group Number

Do you have other insurance?

YesNo

Other Insurance Company

Policy Holder's DOB

Date

Policy Holder's Name

First NameLast Name

Social Security Number

Policy Number

Group Number

Family Physician (The doctor you see regularly)

Family Physician *

Office Phone Number

Please enter a valid phone number.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Is your Family Physician the physician that referred you to us (the provider that sent you to us)?*

YesNo

Referring Physician (The provider who sent you to us - we need the doctor's name not where you were seen)

Referring Physician * (required)

Office Phone Number

Please enter a valid phone number.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Financial Policy
Thank you for choosing the ENT Center of Central Georgia (ENT) and/or Georgia Hearing Institute (GHI) as your health care provider. The following is a statement of our financial policy, which we require you to read and sign prior to treatment. We do require payment at the time of service. We accept CASH, CREDIT CARDS AND CHECKS and if needed, offer an extended payment plan which is available with PRIOR CREDIT APPROVAL.

Co-Payments and Deductibles
Office visits typically require a co-payment from your insurance company. Exceptions may include post operative visits for a determined period of time for some surgical procedures (office visit portion only). A deductible is a portion of the bill that is the responsibility of the patient to pay before an insurance company will cover the service. An office visit with our physicians will include a face-to-face encounter and evaluation. Generally, a copayment is required for the visit. In addition, some services and ALL procedures performed in the office require the patient to meet their deductible before insurance pays benefits. If you have not met your deductible, you will be responsible for full or partial payment, depending on your insurance contract. Procedures performed in the office are considered the same as surgery to the insurance company, and are billed as surgery. Please be advised that any outside pathology or laboratory services will be billed separately by those providers.

Diagnostic Procedures
Your office visit today may include a scope being placed in your nose or throat. This is considered a diagnostic procedure, which will be coded to your insurance company as an invasive or surgical procedure. Depending on the specifics of your policy, your insurance carrier will pay all, part, or none of the cost of this procedure. It is the responsibility of you, the insured, to be aware of the limits of your policy prior to this procedure. Any charges not covered by the insurance carrier will be the responsibility of the patient. YOU HAVE THE RIGHT TO REFUSE THE DIAGNOSTIC PROCEDURE.

Guarantee of Payment and Insurance Coverage
It is the policy of the office that you must pay for services when rendered except in the case of surgery and hospitalization. If this applies to you, we will estimate your responsibility of the charges and collect those (when possible) prior to surgery. We will then file your claim and you will be expected to pay any additional portions not covered by your insurance. If you have any questions, please ask about this before you leave the office.

In the event that my insurance company(ies) or other individuals fail to make prompt payment or deny services due to non-eligibility, I hereby give my personal guarantee of payment for all charges herein incurred. This includes all charges related to office visits, procedures performed, diagnostic testing, co-payments, and deductibles. If this account is placed in collections, the undersigned agrees to pay the balance plus costs incurred to collect the debt.

I hereby authorize insurance benefits to be paid directly to the physician and am financially responsible for any non-covered services. I also authorize the physician to release my medical information in the processing of this claim.

If my insurance requires a referral or authorization for my visit, I am responsible for making sure the referral is obtained from my primary care physician or insurance carrier. I also understand that if the referral/authorization is not received prior to my appointment, I agree to pay for all services rendered on the day of the visit.

I have read the Financial Policy. I understand and agree to this Financial Policy. Initials*

Privacy Policy Acknowledgement Statement
I hereby acknowledge that I have been made aware that The ENT Center of Central Georgia and Georgia Hearing Institute have a Privacy Policy in place in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). As a patient, I understand and acknowledge the following:

ENT and GHI have a privacy policy in effect in their office
ENT and GHI have made this policy available to me for review by placing a complete version in the waiting room.
ENT and GHI have made me aware, that as a patient, I can request a copy of this policy for my personal file.

Upon review of the above statements, please sign below acknowledging that you have been advised of the privacy policy implemented by The ENT Center of Central Georgia and Georgia Hearing Institute and have read and understood the acknowledgement form. If you desire a copy of the Privacy Policy, please request one at this time.

Check One*

No, I do not want a copy, by acknowledge the Privacy Policy exists.Yes, I do want a copy of the Privacy Policy.

Initials*

Patient Consent

In consideration of medical services to be rendered to me (herein referred to as Patient) at The ENT Center of Central Georgia and/or Georgia Hearing Institute (herein referred to as ENT), Patient does hereby consent as follows:

Consent and Treatment Authorization
Patient (or the undersigned acting on behalf of Patient), who is requiring medical treatment, does hereby consent to the rendering of such care and treatment, which may include diagnostic procedures and such medical treatment and care by the Physician or his/her medical staff and assistants under their direction and orders.

The consent to receive medical treatment includes, but is not limited to, examinations, diagnostic and therapeutic procedures, medications, infusions, transfusions of blood and blood products, surgery, anesthesia and any other medical treatment and services which Patient may require. From time to time there will be observers (medical students, residents, etc.) with the physician unless you request otherwise.

In the event that ENT should decide that blood specimens should be provided by the Patient for testing purposes in the interest of safety of those with who Patient my come in contact, Patient does hereby consent to such blood withdrawal and for the testing thereof, as well as the release of test information where this is deemed medically appropriate or required by law.

Consent for RX History Inquiry
I authorize ENT to obtain my Rx history using the Sure-Scripts-Rx Hub network. I understand that this inquire will provide my provider with an accounting of my medical history, reported by pharmacy benefit managers and retail pharmacies. I also understand that sure-Scripts-Rx Hub has certified the use of strict security protocols to align with HIPAA requirements respect to patient privacy. Inquiries and responses are made automatically through secure system-to-system communications.

Disclaimer of Guarantee
Patient hereby acknowledges that the practice of medicine and surgery is not an exact science and that diagnosis and treatment may involve risks of injury and of adverse results. Patient hereby acknowledges that no guarantees have been made to Patient or those acting for Patient as to the results of procedures which Patient may undergo while a patient at ENT.

Acknowledgements of Patient
Patient understands that:

It is customary, absent emergency or extraordinary circumstances, that no substantial or invasive medical procedures be performed upon a patient unless and until the patient has had the opportunity to discuss these procedures with the physician or other health professional so that the patient my be informed of the contemplated procedures.
Each patient has the right to consent, or refuse to consent to any specific procedure or therapeutic course of treatment. If Patient refuses to consent to the administration of blood or blood products, ENT reserves the right to decline to provide medical care if, in the opinion of the Physician, the refusal of blood products poses a serious threat to the Patient.

COVID-19
I understand that the 2019 novel coronavirus, which causes the disease COVID-19, has be declared a pandemic by the World Health Organization, is extremely contagious, and is believed to be spread by person-to-person contact. I recognize that the staff of ENT has put in place reasonable preventative measures aimed at reducing the spread of COVID-19. However, I recognize and accept the risk of becoming infected by virtue of seeking services in-person at ENT.

Permission to email
I, the undersigned, give ENT, its employees or agents, express prior consent to contact me via email if necessary, for the purpose of reviews, practice updates, or events.

Authorization for Release of Medical Information
I hereby authorize the release of any medical information, including information related to psychiatric care, drug and alcohol abuse and HIV/AIDS, confidential information, necessary to process insurance claims or any medical information that is required for any health care related utilization review or quality assurance activities as well as to other physicians for continuity of care issues.

Patient Understanding of Consent
This Consent Form has been adequately and fully explained to Patient, and Patient, by his or her signature, indicates satisfaction as to an adequate understanding of this Consent and its significance and that Patient is voluntarily executing the same.

Validity of Consent
This consent is valid during the entire term of my association with the ENT Center of Central Georgia and/or Georgia Hearing Institute and may be relied upon unless, and until, revoked by Patient, in writing.

Please Initial*

Permission to Authorize Treatment and Provide Health Information

I hereby give my permission to the person(s) listed below to authorize treatment and receive information about the care of the above name patient. In order to obtain information, the party calling must share the patient’s date of birth or Social Security Number *

	Name	Relationship
1.
2.
3.
4.

Initials*

Permission to share my medical information from The ENT Center of Central GA with my healthcare providers through the Central Georgia Health Exchange

We are taking part in an exciting program to improve your healthcare and make office visits easier and more convenient. To do this, The ENT Center of Central GA would like your permission to share your Health Information (as defined below) through the Central Georgia Health Exchange electronic medical record program (Health Exchange). You may already have authorized the sharing of your Health Information into the Health Exchange by signing a permission form when visiting the office of another doctor who participates in Central Georgia Health Network (CGHN). Due to differences in various computer systems, this specific authorization is required by law to release your Health Information to the Health Exchange. If you already have given your permission, then we will update your Health Exchange record with your Health Information from The ENT Center of Central GA. If you have NOT previously given permission, then the Health Information disclosed by The ENT Center of Central GA will NOT be used to update the Health Exchange, even if you check “Yes” below.

I acknowledge that I have read the information set forth below and understand the permission I am giving in this document, and have had the opportunity to have my questions answered about the Health Exchange and this permission form.*

Yes, I agree to participate in the Central Georgia Health Exchange electronic medical recordNo, I do not agree to participate in the Central Georgia Health Exchange electronic medical record

Name of Representative

First NameLast Name

I, the above named Representative, do hereby state that I am authorized to sign this permission on behalf of the patient on the following basis (Relationship to Patient). [A signed copy of this permission will be provided to the patient/representative]

Initials*

This authorization will allow The ENT Center of Central GA to disclose your Health Information so that it can be shared with other providers of healthcare to you (including doctors, nurses, and other health professionals, as well as hospitals and other healthcare facilities) and CGHN, through the Health Exchange electronic medical record system. Only authorized healthcare providers and their contractors, and others whose job it is to maintain, secure, monitor and evaluate the operation of the information system and quality of care, would be able to access your Health Information. The Health Exchange system will allow your providers access to your Health Information more quickly and accurately than with paper charts.

By signing this form, I authorize The ENT Center of Central GA to use and disclose my Health Information and to make such Information available through the Health Exchange to other healthcare providers who need access to my Health Information for the purposes described in this document. The Health Information may include, but is not limited to the following: Information contained in medical records; physicians’ records; surgeons’ records; x-rays, CAT scans, MRI films, photographs, or other radiological, nuclear medicine or radiation therapy films; pathology materials, slides or tissues; laboratory reports; genetic testing results; discharge summaries; progress notes; consultations; prescriptions; records of child abuse, spousal abuse, drug abuse and alcohol abuse; HIV/AIDS and sexually transmitted diseases diagnosis or treatment; physicals and histories; nurses’ notes; patient intake forms; correspondence; social workers’ records; insurance records; consents for treatment; and any other documents concerning any treatment, examination, periods of hospitalization, confinement, diagnosis or other information concerning my physical or mental condition.

Information disclosed pursuant to this permission may no longer be protected by federal health information privacy laws and may be subject to redisclosure. However, the Health Exchange system incorporates access controls, encryption technology and other security features designed to protect the privacy and security of your Health Information. In addition, access to the Health Exchange will be limited to only those users who have agreed to use the Health Exchange consistent with your permission. Information shared through the Health Exchange will be used and disclosed for the following purposes: clinical care; obtaining reimbursement for health care services; for administrative functions related to the provision of and payment for care; quality monitoring and improvement; and administrative management of the Health Exchange and of CGHN.

You can learn more about the Central Georgia Health Exchange by reading the information booklet, “A Guide To The Central Georgia Health Exchange” that is available at the CGHE website (https://www.CGHE.net) or on request from your doctor’s office.

I understand that I may withdraw this permission by giving written notice to administrator, Central Georgia Heath Exchange MSC 98, 777 Hemlock Street,
Macon, GA 31201. Any withdrawal of permission will be effective except to the extent action already has been taken in reliance on this permission. This permission will expire automatically if the Central Georgia Health Exchange program is discontinued.

I understand that my eligibility for treatment or any healthcare benefits cannot be conditioned on whether I sign this permission. However, to the extent I have refused permission, I understand that my Health Information will not be available to other providers (including The Medical Center of Central Georgia) through the Central Georgia Health Exchange.

Digital Signature Authorization:*

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.

Signature*