Medical Authorization (Page 2 of 2) in pdf

2765 Bee Caves Road, Suite 205

Austin, TX 78746

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1730 E. Whitestone Blvd., Suite 100

Cedar Park, TX 78613

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4112 Links Lane, Suite 204

Round Rock, TX 78664

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512-328-7722

Fax: 512-328-7724

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RELEASE OF INFORMATION

I authorize Ear, Nose & Throat Center of Austin to release any information to any physician involved in my care, hospital,

and/or my insurance company including the diagnosis and the records of any treatment or examination rendered to me

during the period of such Medical and Surgical care.

ASSIGNMENT OF BENEFITS

I authorize and request payments of insurance benefits directly to Ear, Nose & Throat Center of Austin otherwise payable to

Me. I further certify I have provided Ear, Nose & Throat Center of Austin a complete list of the insurance companies with

which I have Medical and/or Surgical coverage.

CONSENT TO TREATMENT

I authorize Ear, Nose & Throat Center of Austin and/or authorized persons employed by them to perform and/or initiate

medical evaluation and treatment and authorize or order related services on my behalf.

FINANCIAL AGREEMENT

Unless other arrangements have been made in advance by either you or your health coverage carrier, payment in full is due

at the time of service. Acceptable methods of payment are cash, personal check, Visa, MasterCard, Discover, and American

Express. There will be a $25 fee on any returned checks.

We have made prior arrangements with many health plans to accept an assignment of benefits. We will submit a claim to

those plans for which we have an agreement and will only require you to pay the authorized deductible and co-payment at

the time of service. After the claim has been considered, we will bill you for any balance not previously paid. If you have

insurance coverage with a plan that we do not have a prior agreement, we will prepare and send a claim for you on an

unassigned basis. This means our charges for your care and treatment are due at the time of service and your insurer will

send their reimbursement directly to you.

Your insurance policy is a contract between you and your insurance company; the doctor is not involved. If you have

questions or concerns regarding your plans coverage on procedures, services considered screenings, medications or

particular conditions, you are responsible for obtaining this information prior to your appointment. You agree to pay in full for

all services considered “non-covered” services per your insurance policy if you choose to have the service provided.

If your insurance company does not pay in consideration of the services provided, or you do not have insurance, you agree

to pay all charges of Ear, Nose & Throat Center of Austin. Each bill is due and payable upon presentation or mailing of a

statement to you. Should the account become delinquent, you agree to pay all costs of collection, including interest applied

by a collection agency and attorney fees. Any suit filed may be brought in the county where the services are rendered.

Please Initial Below

___________Specific to the field of Otolaryngology, your physician may need to perform certain procedures for

proper diagnoses of your condition. This may include, but is not limited to, fiberoptic examination of the voicebox,

throat or sinuses. Most insurance carriers consider these exams to be surgical procedures and therefore are

subject to surgical deductibles and copay as they apply. Payment for these procedures are due at the time of

service.

I agree that all of the information provided is current and correct to the best of my knowledge. I agree to notify Ear, Nose, &

Throat Center of Austin of any changes to the information provided in this form as soon as possible.

Patient Name (please print) __________________________________________

Signature of Guarantor_____________________________________________Date_________________________

Medical Authorization Page 2

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