Nanticoke Ear Nose Throat Associates Seaford Delaware Nanticoke Memorial Hospital Private Practice Medicare Medicaid

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Nanticoke Ear, Nose, & Throat Associates
Office Policies

We would like to welcome you to Nanticoke Ear, Nose & Throat Associates, P.A. This is a private practice that cares for a variety of patients. We accept most private insurance carriers, Medicare and Medicaid. Everyone is treated equally and with respect.

As your healthcare provider, we expect you to attend all scheduled appointments, have all necessary laboratory work and testing completed, and take any medications as prescribed.

Again, welcome to Nanticoke Ear, Nose & Throat Associates. We will strive to provide you with optimal care and respect, and we ask the same in return.

Joseph P. Olekszyk, D.O.,M.Sc.

Below is a list of some of our office policies:

• We allow a fifteen (15) minute grace period, and anyone arriving after that time will be asked to reschedule. This grace period is a privilege not to be abused.

• We require that all current insurance cards be presented at registration. If these are not available, you will be asked to pay for your visit or the appointment will be rescheduled.

• Children under the age of 18 must be accompanied by a parent or legal guardian. A signed note by the parent or legal guardian will be accepted prior to the visit.

• We require 24 hour advance notice if you are unable to keep your appointment. There will be a $50.00 fee for No-Show appointments.

• There is a minimum administrative fee of $10.00 to copy records. We require 24 hours advance notice and payment is due prior to providing this service.

• There is a administrative fee of $25.00 to have claims completed. We require 24 hours advance notice and payment is due prior to providing this service.

• All co-pays and self-paying patients are expected to pay in full at the time of your visit. There will be a $30.00 service charge for all returned checks.

• Prescriptions requested by 12 noon will be called in to the pharmacy by 5:00 p.m. that same business day.(non-narcotic prescriptions only) If you make a request on Friday after 12 noon, your prescription will be called in by Monday at 4:30 p.m.

• We apply finance charges to accounts over 60 days.

• Should your account go to collections, you will be responsible for any collection fees or commissions associated with that assignment.

Nanticoke Ear, Nose, & Throat Associates
Patient Registration Form

PATIENT NAME:

BIRTHDATE:

AGE:

ADDRESS:

GENDER:

MARITAL STATUS:

MALE

FEMALE

MARRIED

SINGLE

HOME PHONE:

WORK PHONE:

CELL PHONE:

EMPLOYER:

SSN:

EMPLOYER ADDRESS:

E-MAIL:

REFERRING PHYSICIAN:

FAMILY PHYSICIAN:

GUARANTOR NAME:

BIRTHDATE:

ADDRESS:

GUARANTOR SSN:

EMERGENCY CONTACT:

EMERGENCY PHONE:

(CHECK IF SAME)

PRIMARY INSURANCE INFORMATION

DATE OF ACCIDENT:

RELATIONSHIP TO PATIENT:

SELF

SPOUSE

CHILD

OTHER

SUBSCRIBER NAME:

ADDRESS:

(CHECK IF SAME)

GENDER:

FEMALE

MALE

HOME PHONE:

WORK PHONE:

EMPLOYER:

SSN:

EMPLOYER ADDRESS:

BIRTHDATE:

GROUP NUMBER:

COPAY AMT: $

INSURANCE COMPANY:

POLICY NUMBER:

SECONDARY INSURANCE INFORMATION

DATE OF ACCIDENT:

RELATIONSHIP TO PATIENT:

SELF

SPOUSE

CHILD

OTHER

SUBSCRIBER NAME:

ADDRESS:

(CHECK IF SAME)

GENDER:

FEMALE

MALE

HOME PHONE:

WORK PHONE:

EMPLOYER:

SSN:

EMPLOYER ADDRESS:

BIRTHDATE:

GROUP NUMBER:

COPAY AMT: $

INSURANCE COMPANY:

POLICY NUMBER:

ASSIGNMENT: I assign & request payment of Insurance/Medicare benefits to the undersigned physician for services provided. I am financially responsible for any non-covered services. Nanticoke Ear, Nose, and Throat Assoc., PA is billing my insurance as a courtesy to me.

RELEASE: I hereby authorize the undersigned physician to furnish information to my insurance carrier(s) concerning my care.

Medicare and Medigap Only

ASSIGNMENT: I assign & request payment of Medicare and Medigap benefits to the undersigned physician for services described. I am financially responsible for any non-covered services. Nanticoke Ear, Nose, and Throat Assoc., PA is billing my insurance as a courtesy to me.

Nanticoke Ear, Nose, & Throat Associates
Patient Health History Form

PATIENT NAME:

TODAY'S PROBLEM:

CURRENT MEDICATIONS:
(and/or Herbal Supplements)

PAST OR PRESENT MEDICAL PROBLEMS/HISTORY:
(Please describe anything we should know about your health)

PREVIOUS SURGERIES:

DATE:

LIST ANY FOOD/DRUG
OR CHEMICAL ALLERGIES:

ALLERGIES:

HIVES:

WHEEZING:

PET/ANIMAL EXPOSURE:

Yes

What animals?

What kind of flooring/rugs at home?

Any family members ever had allergy shots?

Yes

What kind of heating system at home?

If yes, list allergies:

Nicotine Products:

Yes

Alcoholic Beverages:

Yes

Drug Use:

Yes

Noise Exposure:

Yes

SOCIAL HISTORY:

Amount
per day:

For how long?

Type of noise exposure:

FAMILY MEDICAL HISTORY/PROBLEMS :

Problem:

Relationship to you:

Patient Information Release

According to the Health Insurance Portability & Accountability Act we are not permitted to release any information about you without your permission. Please list the person(s) to whom we can release your information:

I have been seen by healthcare personnel on the following dates, and I agree to pay any balances due from this visit that are not covered by my health insurance:

PATIENT NAME:

Name                                                Relationship

Name                                                Relationship

Name                                                Relationship

Name                                                Relationship

Signature:                                            Date:

Signature:                                            Date:

Signature:                                            Date:

Signature:                                            Date:

Signature:                                            Date: