PLEASE PRESENT A COPY OF ALL INSURANCE CARDS TO RECEPTIONIST
IF YOU HAVE MEDICARE, PLEASE ANSWER QUESTIONS ON PAGE 2 BELOW
1. Insurance Company
2. Insurance Company
Insured Name
Insured Name
Insured ID#
Insured ID#
***PREFERRED METHOD OF PAYMENT****
CHECK CASH CREDIT CARD (M/C OR VISA)
AUTHORIZATIONS - Please read and sign:
I authorize payment to ENT Carolina, P.A., or directly to me for services rendered. I authorize such exams, treatments and medications as may be prescribed by the designated physician.
I understand that I am financially responsible for all charges for treatment rendered to me, whether covered by insurance or not. I authorize the release of any medical
information requested by my insurance company or any public agency which assists in payment for my medical care. I authorize release of any medical information to my primary care physician.
(Parent sign if minor) SIGNED:__________________________________ DATE:________________
MEDICARE MSP QUESTIONNAIRE
Patient's Name:
Date of Service
Are you enrolled in hospice?
Yes
No
Are you enrolled in a Medicare HMO?
Yes
No
Are you or your spouse currently employed?
Yes
No
Are you covered under group health insurance through your or your spouse's employer?
