Referring Physician Name*3
Primary Care Physician*Name of doctor and practice if you have a primary care physician4
Date of Birth mm/dd/yyyy*13
Primary Phone*include area code16
Primary Phone Provided Is?*17
Employer Phone No.*24
Preferred Reminders Method*29
Cell Phone*For text reminder30
Are you covered by insurance?*32 Are you the primary subscriber?*33
Employer (if different)*34
Subscriber's Name*Put Self if your are the primary or n/a if not covered by insurance35
DOB (if different)*mm/dd/yyyy - Put Self if your are the primary or n/a if not covered by insurance36
Phone (if different)*37
Full Address (if different)*38
Name of Primary Insurance*Put n/a if you're not covered by insurance39
Primary Group Number*Place Group #40
Primary Policy Number*Put n/a if you're not covered by insurance41
Name of Secondary Insurance*42
Relationship (friend, wife, neighbor, etc.)*47
Phone (include area code)*48
Secondary contact phone*49
Consent to Treatment, Medical Records Release and Insurance Appeals
I hereby request and consent to treatment for myself or my child at San Francisco Otolaryngology Medical Group.
I authorize the release of any medical records or other information necessary for the processing of medical claims on behalf of myself or my child.
I hereby consent for San Francisco Otolaryngology Medical Group to act on my behalf in pursuing any insurance appeals necessary to obtain payment for services rendered. I acknowledge that insurance appeal advocacy does not constitute legal representation, and that I may retain outside legal counsel to participate concurrently, if I so choose.51
Signature of patient or parent/guardian - TYPE NAME AS SIGNATURE*I understand that an electronic signature, in this case my name typed as signature, has the same legal effect and can be enforced in the same way as a written signature.52
Please be prepared to pay your co-payment and any outstanding balance at the time of your visit. You may be responsible for services defined by your insurance as denied or non-covered.
Please bring your current insurance I.D. card to every appointment. If we are unable to verify your insurance coverage or authorization, you may reschedule your appointment to a later date, or you may elect to keep your appointment that day. If you keep your appointment, you will be required to pay for the visit; we will make a reasonable attempt to bill your insurance and request a refund directly to you.
If your insurance requires authorization from your primary care physician, please make sure that you have one that is valid for your visit and that it covers any necessary tests needed.
We will be happy to bill your secondary insurance as a courtesy. If your insurance fails to pay within 30 days of the primary insurance payment, the balance will be forwarded to you.54
If you would like an electronic copy of your medical record, please submit a written request by mail or via our online records request form. There is a $15 processing fee for each request.56
Notice of Privacy Practices Acknowledgement
This is required by the privacy regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). This notice describes how medical information about you may be used and disclosed, and how you can get access to this information. Please review it carefully. It is available in print form or electronic download.
By signing below, you acknowledge that:
You have been provided with and understand that San Francisco Otolaryngology Notice of Privacy Practices provides a complete description of the uses and disclosures of your health information.
As part of your health care, San Francisco Otolaryngology Medical Group originates and maintains health records describing your health history, symptoms, examination and test results, diagnosis, treatment and any plans for future care or treatment.
San Francisco Otolaryngology reserves the right to change its Notice of Privacy Practices and prior to implementation of this will mail a copy of any revised notice to the address you have provided, if requested.
You have the right to review San Francisco Otolaryngology Medical Group Notice of Privacy Practices.58
Signature of patient or parent/guardian - TYPE NAME AS SIGNATURE*I have read and understand the above information. I understand that an electronic signature, in this case my name typed as signature, has the same legal effect and can be enforced in the same way as a written signature. The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize San Francisco Otolaryngology or insurance company to release any information required to process my claims.60
NOTICE NEW PATIENT: Upon submitting this form, you will be directed to a page that gives you access to our Health History form. Please complete the Health History form as it will accompany this registration form. Click the blue CareSubmit button below when this registration is filled out completely and accurately.61