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Florida Gulf Coast Ear, Nose & Throat, LLC
PATIENT NAME:____________________________________________________________________ Last Date of Birth:______________ Age: ______ Sex: M - F Marital Status: S M D W SEP Name of Spouse / Parent if Patient is a Minor_______________________________________________________ Social Security#:_______________________ Email Address:__________________________________________Cell Phone#:___________________ Mailing Address:_____________________________________________Home Phone#:_________________ Northern Address:_____________________________________________________________________
Employer:_______________________________________________Business Phone#______________________
ALL CHARGES ARE DUE AND PAYABLE AT THE TIME OF SERVICE, FORMS OF PAYMENT: CASH,
CHECK, MONEY ORDER, VISA, MASTERCARD.
HOW DO YOU INTED TO PAY FOR TODAY’S VISIT:____________________________________________
Who is your Primary Care Physician? ______________________________________________________________
Who referred you to Our Practice
?_____________________________________________________________
Whom may we contact in the case of an emergency?

NAME:_______________________________PHONE:____________________RELATIONSHIP:_____________
AUTHORIZATION TO DISCLOSE MEDICAL INFORMATION
DO WE HAVE PERMISSION TO TALK TO FAMILY MEMBERS?________YES _______NO
IF YES, PLEASE PROVIDE NAME AND PHONE NUMBER:
Name:________________________Phone:______________________Relationship:_____________________
Name:________________________Phone:______________________Relationship:_____________________
MAY WE LEAVE A DETAILED MESSAGE ON YOUR HOME ANSWERING MACHINE? _____YES ______NO
MAY WE CONTACT YOU OR LEAVE A MESSAGE AT OUR WORK? _____YES _____NO
HIPAA Privacy Act

I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND ACCURATE.

I hereby authorize the examination and treatment and authorize the release of medical information to insurance or Medicare carriers. I will be responsible
for payment of services my insurance or Medicare does not cover (non-covered) services performed with my permission in this office that my insurance
company has contracted to another provider or facility. I will be responsible for knowing the providers and facilities in my insurance company’s network
and for accepting referrals to only these providers and facilities. If I accept a referral to a provider or facility outside my insurance network, I will be
responsible for any charges not covered by my insurance company or Medicare. I hereby authorize my insurance benefits be paid directly to FLORIDA
GULF COAST EAR, NOSE & THROAT, LLC. A copy of this authorization is as valid as the original. I understand I have the right to review FLORIDA
GULF COAST EAR, NOSE & THROAT, LLC’S Notice of Privacy Practices, located in the waiting room, and to obtain a copy by asking the receptionist. I
also give permission for FLORIDA GULF COAST EAR, NOSE & THROAT, LLC to discuss my medical test results and condition with the individual(s)
listed above.
Signature of Patient, Parent, or Legal Guardian:________________________________________Date:__________________
Medical Information Sheet
Patient Name:__________________________

Reason for visiting our office today
?____________________________________________________________
List Major Medical Problems: (Check if you currently have or have had in the past)
High Blood Pressure__

List all Previous Surgeries:_____________________________________________________________________________
List Known Allergies:__________________________________________________________________________________
Do you require pre-medication prior to surgical procedures? Yes____ No___
Family History: List relationship to you if Yes is checked
Yes___No___ ____________ Bleeding Problems Yes___No___ ____________
Do You Smoke
? I Quit___ When?______Never____Cigarettes____Cigars____Pipe____Snuff or Chew_____

Do You Consume Alcohol
? None______Less than 1 per Day _____1-2 per Day_____More than 2 per Day_____
Other Medical Problems:______________________________________________________________________________
Please Circle any of the following that you experience:
Ear Pain, ear drainage, ringing, hearing loss, nasal congestion, nasal drainage, bleeding, sore throat, difficulty swallowing, neck pain, neck swelling Blurry vision, double vision, changes in vision acuity Cardiovascular: Palpitations, chest pain, ankle swelling, leg cramping Respiratory: Shortness of breath, coughing, wheezing, and coughing up blood Nausea, vomiting, diarrhea, constipation, heartburn, abdominal pain, dark or bloody stools Pain on urination, bloody urine, frequency or hesitancy of urination Dizziness, fainting spells, numbness, weakness, headache, stroke Heat or Cold intolerance, weight change, increased thirst Patient Name:__________________________

What Pharmacy do you use and the location?_______________________________________________

Medications
(Please circle current use and underline past use)

Antihistamines
: Atarax Allegra Allegra-D Allerx Benadryl Clarinex Claritin Claritin-D Tavist
Zyrtec-D Zyrtec Over the Counter:_____________________________________________________ Symptoms: Improved Not Improved Sedation Reaction-_______________________________
Decongestants
: Entex Profen Sudafed Duratuss Other_________________________________________
Symptoms: Improved Not Improved Sedation Reaction-_______________________________
Nasal Sprays
: Astelin Atrovent Beconase Flonase Nasarel Nasochrom Nasocort Nasonex Rhinocort
Vancenase Afrin Other:________________________________________________________________ Symptoms: Improved Not Improved Sedation Reaction-_______________________________ How often do you dose this medication?______________________________________________________
Asthma Inhalers
: Aerobid Azmacort Beclovent Flovent 44,110, or 220 Intal Pulmicort Tilade Vanceril
Symptoms: Improved Not Improved Sedation Reaction-_______________________________ How often do you dose this medication?______________________________________________________
Bronchodilators
: Albuterol Alupent Atrovent Brethaire Combivent Foradil Maxair Proventil Serevent
Symptoms: Improved Not Improved Sedation Reaction-________________________________ How often do you dose this medication?______________________________________________________
Theophylline
:
Slo-Bid Theo-Dur Theo-24 Unidur Uni-Phyl Symptoms: Improved Not Improved Sedation Reaction-__________________________________
Leukotriene Modifiers
: Accolate
Symptoms: Improved Not Improved Sedation Reaction-__________________________________
Oral Bronchodilators
: Albuterol Tabs Proventil Tabs Volmax Volspaire
Symptoms: Improved Not Improved Sedation Reaction-_________________________________
Oral Steroids
:
Medrol Prednisone Prednisolone Sterapred Symptoms: Improved Not Improved Sedation Reaction-_________________________________ How often did you dose this medication?_____________________________________________________
Eye Allery Drops
: Alocril Optivar Patanol Zaditor Other_________________
Symptoms: Improved Not Improved Sedation Reaction-_________________________________
Proton Pump Inhibitors
: Nexium Aciphex Protonix Over the counter_______________________________________
Symptoms: Improved Not Improved Sedation Reaction:_________________________________
Medications not listed Above
:___________________________________________________________________________
Immunizations:
Insurance Information
Patient Name:________________________________Date:___________________________

Primary Insurance Carrier Name:_________________________________________________
Policy Holder Name: _______________________________Relationship:_________________
Date of Birth of Insured:______________Social Security # of Insured:____________________

Policy ID#:___________________________Group #_________________________________
Secondary Insurance Carrier Name:______________________________________________
Policy Holder Name:________________________________Relationship:________________
Secondary Insurance Policy #:________________________Group #:____________________
If Patient is a Child Responsible Person/Guardian Information:

Name:__________________________Relationship:______________Phone:______________
Address:____________________________________________________________________
Social Security #___________________________Date of Birth:________________________
Insurance Policies and Payment Procedures

In an Era of Managed Care we cannot possibly know the terms of your individual policy.
Please review your plan booklet or check with your insurance representative if you are
unsure whether services at Florida Gulf Coast Ear, Nose and Throat are covered under
your policy. It is your responsibility to know if the services you are having needs to be
pre-authorized or not.
Most insurance plans have a specialty office visit co-pay; this co-pay applies to the doctor
visit portion of your bill only. If the doctor provides a service at the same visit, such as
using the microscope to look in the ear or uses an endoscope to look in the nose; a scope
to look into the throat; order hearing tests, allergy tests and allergy injections, this is
considered an ancillary charge with your insurance company and most likely you have a
deductible to be met and then a percentage of out of pocket amount which is usually
20%. This is in addition to the co-pay assigned to specialists.
If we order hearing tests or allergy testing we recommend that you call your insurance
carrier and ask them how these services are paid in a doctor’s office.
You will be expected to pay your deductible and co-payment amounts at the time services
are rendered. If you are unable to do so, we ask that you contact the office manager to
see if other payment options can be made.
Signed:___________________________________________Date:__________________
Florida Gulf Coast Ear, Nose & Throat, LLC PAYMENT POLICY:

We accept Medicare assignment and bill secondary insurance only if you have a Medigap plan (one where
Medicare automatically crosses over). Your co-payment and deductible are due at the time of service; we accept
payment in the form of cash, checks or credit cards. Non-Medicare patients are expected to pay at the time of
service unless we have an established relationship with your insurance carrier.
In order to establish optimal relations with our patients and to avoid misunderstanding and confusion regarding
payment policies, our staff is trained to consistently inform you of the financial payment policies of this office.
Payment is required for all services at the time they are rendered. We accept payment in the form of CASH,
CHECKS, and CREDIT CARDS (Visa and MasterCard Only). When you provide a check as payment you
authorize us to either use information from your check to make a one-time electronic fund transfer from your
account or to process the payment as a check transaction. When we use information from your check to make an
electronic funds transfer, funds may be withdrawn from your account as soon as the same day you make your
payment. A returned check fee of $40.00, or maximum allowable by law, will be electronically debited from your
account in the event your electronic transfer is returned from your financial institution. Any balances not paid
within 60 days will accrue interest in the amount of 12% per month.
Note a $40.00 fee will be charged to all patients who fail to cancel their scheduled appointments within 24
hours of the appointment.
A fee of $20.00 will be charged to patients whose prescriptions need to be refilled
while up north. We try our best to make sure that patients have enough refills on their prescriptions before they
leave for the north, and feel the time and cost of calling or faxing prescriptions long distance has to be the
responsibility of the patient.
MEDICAL/PAYMENT AUTHORIZATION:
I hereby authorize my Health Insurance plan to make direct payment to Florida Gulf Coast Ear, Nose and Throat,
LLC, Dr. Samuel L Hill III, Dr. Patrick M. Reidy for all services provided to me, unless I have paid in advance
for said services.
I hereby authorize Florida Gulf Coast Ear, Nose and Throat, LLC to release any information acquired in the
course of my treatment to my Health Insurance carrier, if needed for payment of my claim.
I hereby authorize photocopies of this form to be as valid as the original, and authorize the above
Medical/Payment Authorization for as long as Florida Gulf Coast Ear, Nose and Throat, LLC remains my
physician.
I understand I am responsible to pay for services provided to me, and any account balance that has not been paid
within 90 days is subject to be sent to collection, and I am responsible for the 40% collection fee, charged by the
Collection Agency.
SIGNATURE OF THE PATIENT OR LEGAL GUARDIAN AGREEING TO THE ABOVE
MEDICAL/PAYMENT AUTHORIZATION:
SIGNED:_______________________________________DATE:__________________
REV 7/2010

Source: http://www.floridagulfcoastent.com/download/80/NewPtInforForms.pdf

Part

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