Columbus Otolaryngology Clinic
 

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Form 1 of 5 - Minor (Patients 18 and under) - Due to Accident or Injury

 

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COLUMBUS OTOLARYNGOLOGY CLINIC

NILA M. NOVOTNY, M.D.

4508 38TH STREET, SUITE #152, COLUMBUS, NE 68601-1668

(402) 563-4500 FAX (402) 563-3520

The information you provide to this office helps us to help you with important items such as: future appointments, insurance claim processing, payment on your account, etc. It could also be critical in the event of an emergency.

NAME·OF·MINOR·CHILD·-·Last·Name· First·Name· Middle·Initial·

Street·address· PO·Box·or·Suite·Number· City· State· Zip·

Home phone· Work phone· Cell·phone·

Employer· Occupation· Marital·status·

Names·&·ages·of·children·at·home

Social·Security·#·(for·ages·18-26)· Gender· Age· Race·(Optional)·

Birth·date·-·Month· Day· Year·

Email·address·

Preferred·method·of·contacting·you·

Referring·Doctor· Family·Doctor· Other·Professional·Involved·

PERSON·FINANCIALLY·RESPONSIBLE·-·Last·Name· First·Name· Middle·Initial·Relationship·to·the·Patient·

Father's/Guardian's·Name·-·Last·Name· First·Name· Middle·Initial·

Street·address·if·different·than·patient’s· PO·Box·or·Suite·Number· City· State· Zip·

Home·phone· Work·phone· Cell·phone·

Employer· Occupation· Marital·status·

Names·&·ages·of·children·at·home

Social·Security·#· Gender· Age· Race·(Optional)·

Birth·date·-·Month· Day· Year·

Email·address·

Preferred·method·of·contacting·you·

Mother's/Guardian's·Name·-·Last·Name· First·Name· Middle·Initial·

Street·address·if·different·than·patient’s· PO·Box·or·Suite·Number· City· State· Zip·

Home·phone· Work·phone· Cell·phone·

Employer· Occupation· Marital·status·

Names·&·ages·of·children·at·home

Social·Security·#· Gender· Age· Race·(Optional)·

Birth·date·-·Month· Day· Year·

Email·address·

Preferred·method·of·contacting·you·

Next·of·kin·for·emergency·notification·-·Last·Name· First·Name· Middle·Initial·

Relationship·to·patient· Phone·#· Cell·#·

DO·YOU·HAVE·MEDICAL·INSURANCE?· (If·you·have·insurance·cards,·we·will·make·a·copy·of·them·for·you.)

NAME·&·ADDRESS·OF·PRIMARY·INSURER (e.g. Aetna, Blue Cross, Cigna, RCI, etc.)

Subscriber·of·insurance·-·Last·Name· First·Name· Middle·Initial·

Subscriber·of·insurance·-·Social·Security·#·

POLICY#· GROUP#· Is·this·a·PPO·or·HMO·plan?· Name·of·PPO·or·HMO·plan·

Do·you·have·a·copay·for·office·visits?· AMOUNT·


DO·YOU·HAVE·SECONDARY·MEDICAL·INSURANCE?· (If·you·have·insurance·cards,·we·will·make·a·copy·of·them·for·you.)


NAME·&·ADDRESS·OF·SECONDARY·INSURER

Subscriber·of·insurance·-·Last·Name· First·Name· Middle·Initial·

Subscriber·of·insurance·-·Social·Security·#·

POLICY#· GROUP#· Is·this·a·PPO·or·HMO·plan?· Name·of·PPO·or·HMO·plan·

Do·you·have·a·copay·for·office·visits?· AMOUNT·

Services are rendered on a CASH BASIS ONLY unless previous arrangements are made.

I/We authorize payment of medical benefits directly to COLUMBUS OTOLARYNGOLOGY CLINIC/NILA M. NOVOTNY, M.D. I/We also agree that this authorization will be perpetual in nature and a copy of this assignment is a s valid as the original. I/We further agree that should my insurance benefits be insufficient to cover the entire amount of charges, I/We will be responsible for the difference. I/We agree that payments will not be delayed or withheld because of any insurance coverage or the pendency of claims, and all proceeds of insurance are assigned to this Clinic where applicable, but without assuming responsibility for the collection thereof.

I/We agree that the above information is for the purpose of obtaining credit and is warranted to be true, I/We authorize the Clinic or its agent to make a credit investigation, including employment verification.

I/We agree that charges shown by statements are correct and reasonable unless protest within 30 days of original billing date. I/We agree that in the event legal action should be necessary to collect an unpaid balance due for services rendered to me or my family, I/We will pay reasonable attorney’s fees or other such costs as the Court determines proper.

I/We knowing that I/We have a condition(s) requiring examination, diagnosis, medical and/or surgical treatment, hereby consent to such treatment, including photographs, video taping, documentation and storage of medical records, in any form. I/We further acknowledge that no guarantees are made as to the results of such treatment. I/We consent to and authorize the release of medical information to my insurance provider and/or physician and/or other health care provider concerning my/our examination, diagnosis and treatment. You are entitled to a copy of this agreement should you request one.

(MEDICARE ONLY: I REQUEST THAT PAYMENT OF AUTHORIZED MEDICARE BENEFITS BE MADE EITHER TO ME OR ON MY BEHALF FOR ANY SERVICES FURNISHED ME BY COLUMBUS OTOLARYNGOLOGY CLINIC INCLUDING PHYSICIAN’S SERVICES. I AUTHORIZE ANY HOLDER OF MEDICAL OR OTHER INFORMATION ABOUT ME TO RELEASE TO THE HEALTH CARE FINANCIAL ADMINISTRATION AND ITS AGENTS ANY INFORMATION NEEDED TO DETERMINE THESE BENEFITS OR BENEFITS FOR RELATED SERVICES. WE ARE INFORMING YOU THAT SOME SERVICES MAY NOT BE PAYABLE BY MEDICARE IF THEY DEEM THEM TO BE NON-COVERED. YOU WILL BE RESPONSIBLE FOR PAYMENT OF NON-COVERED SERVICES. PLEASE REFER TO YOUR MEDICARE HANDBOOK FOR FURTHER DETAILS ABOUT NON-COVERED SERVICES.)

Have you read and do you agree to the terms shown above?

RESPONSIBLE·PARTY·SIGNATURE·(Please·type·full·name) DATE·-·Month· Day· Year·

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Columbus Otolaryngology Clinic

American Board of Otolaryngology Certified - Founding Member of the American Board of Medical Specialties (ABMS)

Nila M. Novotny, M.D.

COC "Serving the greater Columbus area for over 29 years"

4508 38th St., Suite #152

Columbus, NE 68601-1668

402-563-4500 FAX: 402-563-3520

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