Patient Financial Obligation - Lemont Ent Sc

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Cynthia Go, MD, PhD, FACS
1011 State St, Ste. 120, Lemont, IL 60439 – (630) 243-4505 (Phone/Fax)
Please read this notice prior to signing the Financial Responsibility Form
The amount that your insurance company will pay for your office visit to see Dr. Go may not
be 100% covered which is often the case when you see your primary care doctor. Because
you are seeing a specialist, the costs of your visit may not be paid by your insurance
company and can be applied entirely to your deductible, even if you have a copay.
In addition, any procedures that may be performed in the office to help diagnose your
problem are often applied to your deductible and you are responsible for paying this
amount yourself. Examples of procedures that may be performed to diagnose and treat
your condition include (but are not limited to):
1. Nasal endoscopy (scope used to evaluate your sinuses)
2. Flexible Laryngoscopy (scope used to evaluate your throat and vocal cords)
3. Biopsy
4. Ear wax removal
5. Use of the microscope to evaluate the ear drums
Your visit will be billed to your insurance company first. However, after any contracted
discounts for in-network benefits are applied, the resulting amount will be your
responsibility to pay completely. Lemont ENT, SC will bill you this amount and by signing
the Financial Responsibility Form, you are agreeing to pay the amount that is your
deductible. Further, the office may be able to predetermine the amount that you may owe
for this visit before you leave and we will expect payment at the conclusion of your visit.
There may still be an additional amount owed even after this payment and you will be billed
for this amount.
Lemont ENT, SC
Cynthia Go, MD, PhD, FACS

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