For your convenience, please print out the appropriate forms, complete them along with any other required paperwork and bring them with you to your appointment.
- Patient Registration Form
- Health History Form
- Financial Policy
- Notice of Privacy Practices
- Terms of Service
- Nondiscrimination Statement
- Nondiscrimination Statement Multi-Language
- Your Right to an Interpreter
- Request Medical Records with ChartFast
If you are a new patient transferring to our center please print, complete and bring the Authorization for Medical Release form with you to your first appointment.
Insurance Claims and Payment
Payment is due at time of service. For payment details visit our Financial Policy. This includes all copayments, coinsurances and deductibles. Your insurance card must be presented for verification at each visit.
We accept cash, check, Visa, MasterCard, American Express and Discover.
Ear, Nose and Throat Specialists are in-network providers for many plans, including the following:
- Arise Health Plan
- Humana and Humana One
- Network Health Plan
- Common Ground
- United Health Care
We encourage you to contact your insurance carrier directly regarding coverage. If your plan is not listed, please contact our office at (920) 969-1768 to discuss your options.