Please be aware that certain procedures performed in our offices are not included in the standard office visit. These procedures will be billed separately and in addition to office visit charges. We have become aware that some insurance carriers are classifying these procedures are 'Surgery" and applying the charges to a higher deductible amount. The result may be insurance payment for an office visit but not a procedure. In such cases, payment for the procedure will be due from the patient. Be assured we are following accepted billing and coding guidelines and that all procedures are performed in the best interest of patient care.

Examples of in-office procedures include:

• Flexible laryngoscopy: This procedure involves passing a long thing flexible fiber optic scope through the nasal cavity and into the throat. The fiber optic scope enables the physicians to visualize areas of the throat not readily seen using the laryngeal mirrors.
• Nasal endoscopy: This procedure uses the flexible or rigid scope attached to a light source to view areas of the nasal cavity that cannot be viewed by the physicians using the standard nasal speculum and head mirror.
• Nasal endoscopy with debridement or biopsy: This is the same procedure as above with removal of crusting or tissue.
• Comprehensive Audiometric Examination: One of our Audio Technicians will test your hearing thresholds in a soundproof booth by presenting a series of tones and recording the level at which you respond.
• Tympanogram: A tympanogram measures the movement of the eardrum by varying the pressure in your ear canal.
• Otoacoustic emission test (OAE): An Otoacoustic emission test measures an acoustic response that is produced by the inner ear, which in essence bounces back out of the ear in response to a sound stimulus.

Please speak to the clinical assistant if you have any questions.

THE FOLLOWING DOCUMENT AUTHORIZES ENTC TO:

1. Provide services and treatment.
2. Release records to insurance company(ies), when applicable. Some insurance plans require medical records before paying for services.
3. Release information to those assigned to manage the patient's billing.
4. Release records to accrediting and quality organizations, regulatory agencies, or other persons or entities for health care operations to ensure quality care is being delivered.
5. Release records to share information with providers or staff involved with the patient's care.
6. Release information to ENTC marketing individuals or affiliates who can provide the patient with information regarding available services and goods.
7. Work with your insurance company(ies) to share past, current, and future information strictly for the purposes of managing and coordinating your care or improving the quality of that care.
8. Receive payment directly from insurers, when applicable.

AUTHORIZATIONS

Authorization for Treatment: I consent to the rendering of medical care which may include routine diagnostic procedures and such medical treatment as my physician(s) or other Ear Nose and Throat Consultants of Nevada (ENTC) medical staff consider to be necessary. I may be offered medical services via telemedicine systems that involve the delivery of health care by electronic communication with a provider who is at a different physical location, and I consent to such services. I understand that my medical care and treatment may be provided by physicians, including fellows and residents, medical and allied health students, physician assistants, nurses, and other health care providers. I have read and understand this Authorization for Treatment and understand that no guarantee or assurance has been made as to the results that may be obtained.

Authorization to Release Medical Information**: I authorize ENTC to release all medical information as necessary to:

• All Payers*** for processing health care claims.
• The person(s) I designate as my Billing Addressee/Guarantor for handling the billing, payment, and health care coverage for my account.
• Accrediting and quality organizations, regulatory agencies, public health reporting agencies, or other persons or entities for health care operations.
• My other health care providers for treatment or payment purposes; and
• ENTC entities for the purpose of providing information regarding the services and goods of ENTC and/or its affiliates that may be of interest to me. I understand that, if this information is disclosed to a third party, the information may no longer be protected by federal privacy regulations and may be redisclosed by the person or entity that receives the information in accordance with applicable law. ENTC may not condition treatment, payment, enrollment, or eligibility for benefits on my agreeing to this provision.
• I authorize ENTC and my insurer(s) to share my past, current and future health, treatment and account records about services I’ve received from ENTC and other care providers as needed to manage or coordinate my care and to improve the quality of that care.

Authorization to Assign Benefits and Release Information to ENTC: I authorize my Payer(s) to pay directly to ENTC any benefits due under the terms of my health care plan(s), for services provided by ENTC. I understand ENTC reserves the right to refuse or accept assignment of medical benefits. If I am a Medicare beneficiary, I request payment of authorized Medicare benefits to me or ENTC on my behalf for any services furnished. If my health care plan(s) will not allow direct payment to ENTC or if ENTC chooses not to accept assignment of medical benefits, I agree to pay ENTC all health care payments I receive for services. I authorize ENTC to contact my Payer(s) to obtain all pertinent financial information concerning coverage and payments made under my health care plan(s) and for my Payer(s) to release such information to ENTC.

SERVICE TERMS

Statement of Financial Responsibility: I acknowledge I am responsible for all charges for services provided, including any amount not paid by my health care plan(s), other than billing terms and restrictions under a government program. I authorize ENTC to apply any credit balance on my account to any amounts that I may owe.**Collection Policy: I agree to be financially responsible for all charges incurred, regardless of insurance coverage. In the event my past due balance is referred to our partnered collection agency for non-Payment, I agree to pay all collection and legal fees that may be added to my past due account balance.

I agree that ENTC may obtain financial information, including consumer credit reports to determine eligibility for financial assistance and/or payment options.

Dispute Resolution: I agree that any dispute (including personal injury claims) related to health care services rendered by ENTC is subject to the exclusive jurisdiction of the appropriate court in the state where the provider of the disputed services is physically located when the services are rendered and the law of that state. Any state court action must be venue in the county where the provider of the disputed services is physically located when the services are rendered. These agreements also apply to my legal representatives and next of kin.

Use of Phone: I agree ENTC, its affiliates and agents may use an automated telephone dialing system, pre-recorded messages, and texting, to contact the wireless number(s) and/or residential lines I provide to ENTC for appointment and payment purposes. Notice of Privacy Practices: I acknowledge I have been presented with the ENTC Notice of Privacy Practices, which can be viewed on the patient portal or at www.entc.com. I can request a paper copy during my visit or by calling 702-792-6700.

ATTENTION: This is a legal document. Changes will not be accepted on this form. Requests for any alterations must be made by calling 702-792-6700. By signing, I agree that I understand and accept the terms on this form. I understand I have the right to revoke the authorizations on this form at any time by notifying ENTC in writing, except to the extent that ENTC has already taken action in reliance upon them. These authorizations will remain valid until I revoke them in writing.

• If the patient is 18 years of age or older, the patient must sign and date the form.
• If the patient is 18 years of age or older and is incapable of signing, a legally authorized substitute may sign and date the form. Please indicate your legal authority and include documentation of your relationship:
  Legal Guardian or Conservator Health Care Agent (Health Care Power of Attorney) Other Legal Representative
• If the patient is 17 years of age or younger, the patient’s parent or legal guardian must sign and date the form, unless an exception exists under state or federal law.

Ear, Nose, and Throat Consultants of Nevada is responding to the COVID-19 Pandemic by following the guidelines of The American Academy of Otolaryngologists. Our offices are regularly sanitized with approved products for the elimination of contaminants. We also limit the number of patients in our waiting rooms for your safety. As the patient, you must agree to the following provisions in order to protect you as the patient and us as the provider for your care.

1. Neither I or any of my immediate family members have had any of the following symptoms:
   Cough, fever over 100.5 degrees, sore throat, or loss of smell or taste
2. I have not been in contact with another individual who tested positive for COVID-19 in the past 14 days.
3. I have not tested positive for COVID-19 in the last 14 days.
4. I am not waiting for the results of a COVID-19 test.
5. I agree to be seen alone as a patient unless disability or age considerations are a concern.
6. I agree to have my temperature taken by ENTC staff upon arrival and prior to being seen as a patient.
7. I agree to be solely an fully responsible for the potential exposure which may occur over the course of my consultation and treatment.
8. I agree to release, discharge, and/or otherwise indemnify ENTC, its providers and staff against any claim in the future, on behalf of myself or others.

Ear Nose and Throat Consultants of Nevada provide quality treatment and care in a timely manner to all our patients. We schedule appointments so that each patient receives the right amount of time to be seen by our provider and staff. We have implemented a “no-show” policy which enables us to better utilize available appointments for our patients in need. The following policy is with regard to patients who fail to keep their scheduled appointments for office visits, in office procedures and surgeries.

Please be courteous and call our office promptly if you know you cannot make your appointment. This time will be allocated to another patient. Available appointments are in high demand and your early cancellation will be given to another patient.

Office Visits:

It is very important to keep your scheduled appointment with us, and arrive ON TIME, 30 minutes early for new patients. As a courtesy, and to help patients remember their scheduled appointments, ENTC sends text messages and email reminders 7 days, 3 days and 1 day prior to your appointment time. If you do not cancel or reschedule your appointment within this 24-HOUR PERIOD, we will assess a $40.00 “no show” service charge to your account.

In office Procedures:

A patient who fails to show for their procedure or notify the office within 2 business days of their scheduled appointment time, shall be subject to a cancellation fee of $150.00.

Surgeries

Patients who fail to show for their scheduled surgery appointment, did not notify the office within 2 business days or cancel less than 7 days of their scheduled surgery appointment due to any other reason than COVID-19 or severe documented illness, shall be subject to a “no-show” cancellation fee of $250.00.

If any appointment is cancelled by the physician or office, the patient is NOT subject to charge.

If your schedule changes and you cannot keep your appointment time, please contact us so we may reschedule you and accommodate those patients who are waiting for an appointment. As a courtesy to our office as well as those patients who are waiting, please give us 24 HOUR ADVANCE NOTICE.

This “no-show fee” is not reimbursable by your insurance company. You will be billed directly for it.

Please sign by typing your name and date of birth.