Financial policy

• Co-pays must be paid at the time of service, as required by your insurance company. We accept cash, check, Visa, Mastercard, and Discover. A $5 billing charge will be added to all co-pays not made on the day of service. Also, there will be a $30 fee for all returned checks.

• Patients who fail to keep an appointment or cancel less than 24 hours prior to the scheduled appointment time will be assessed a $25 no show fee.

• If your insurance company requires you to have a referral from your primary care physician in order to be
  treated by our doctors, please verify that this process has taken place. If a referral is not in place, you cannot be
  seen until one is received.

•  If you do not have insurance (self-pay), payment in full is expected at the time of service. Please be prepared to
  pay $150 for a New Patient visit or $50 for an Established Patient visit upon arrival. The balance for your office
  visit and/or procedure will be collected at check out. The balance owed will be determined by the level of service provided.

• In case of divorce, the parent seeking treatment must supply the responsible parent's billing and insurance
  information. We may also need to ask for a copy of the divorce decree as to determine who is responsible for
  the bill, especially if it is not the parent bringing the patient.

•  Accounts that are more than 90 days past due could be subject to a collection action. Any legal activity would
  cause a breach in the physician/patient relationship, resulting in a possible discharge from the practice. There
  will be a 25% administration fee charged to your account, payable by you, if your account is sent to a collection
  agency for payment.

•  A parent or legal guardian must accompany patients who are minors (under 18 years of age) on the patient's first visit. Future appointments must be accompanied by an adult but does not have to be the legal guardian.

• Being a surgical office, we realize that disability and Family Leave Act forms will need to be completed by our
  office. We ape happy to complete these forms, however, there will be a charge per form based on the length of
  the form. Copies of your medical records are available to you. There may be a fee charged based on how many
  pages you are requesting.

• Please bring your insurance card(s) with you to every visit. We will file accepted insurance claims on your behalf. Please remember that having insurance is not a guarantee of payment. You are responsible for any balance designated as your responsibility by your insurance company including co-pays, co-insurance and deductibles.

      I authorize my insurance benefits be paid directly to Toledo ENT, Inc.

      I authorize Toledo ENT, Inc. to release pertinent medical information to my insurance company when requested, or to facilitate payment of a claim.

      I have read, understand, and agree to the above Financial Policy,

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                            Printed Name                                                                                                                                   Date

                                              Signature of Patient/Responsible Party                                                                                                                               REV02/01/2010