Privacy Practice

Submitted by admin on Fri, 08/12/2011 - 3:04pm

Submission Date

Month

Day

Year

Submission Time

First Name: *

Last Name: *

Date of Birth: *

Month

Day

Year

Insurance Limitations

(Enter the financially responsible party's name below)

Most insurance carriers require a written referral form from a Primary Care Physician prior to service provided. Patients or person responsible for the patient must (1) obtain physician referrals and (2) contact the insurance carrier to verify benefits prior to service. At the time of service, patients are responsible for payment for non-covered services, deductibles and co-insurance.

Acknowledgement of Receipt of Privacy Policy

By placing a check in this box, you are indicating that you have read and understand the Privacy Policy document. At the time of your first visit, you will be asked to sign a hard copy version of this form so that we may have your signature on file.

Authorized Persons

I give The ENT Center of New Braunfels permission to discuss my protected health information with the following family members, significant others or friends:

Name:

Relationship:

Telephone Number: ( )

- -

Work/Cell #: ( )

- -

Name:

Relationship:

Telephone Number: ( )

- -

Work/Cell #: ( )

- -

Consent to Treat

By placing a check mark in this check box, I hereby volunteer consent to my treatment at the ENT Center of New Braunfels, and authorize such treatments, examinations, and diagnostic procedures.

CAPTCHA

Please fill out the characters you see in the box below. This is to help reduce submissions entered by automated bots. Thank you.

What code is in the image? *

Enter the characters shown in the image.

Main menu

Privacy Practice

Contact Info

Hospital Affiliations

Guadalupe Regional Medical Center

Christus Santa Rosa Outpatient Center

Christus Santa Rosa

Central Texas Medical Center

Patient Forms