Patient Information Form

Insurance Information

Please have an insurance card & driver’s license available at the time of appointment. It is necessary to have accurate information to file your claim. If the information provided below are incorrect or incomplete you will be financially responsible for all charges rendered.

302 Merchants Walk, Suite 100, Tuscaloosa, AL 35406

Phone: (205) 523-9300 Fax: (205) 523-9301 www.alabamaentspecialists.com

302 Merchants Walk, Suite 100, Tuscaloosa, AL 35406

Phone: (205) 523-9300 Fax: (205) 523-9301 www.alabamaentspecialists.com

302 Merchants Walk, Suite 100, Tuscaloosa, AL 35406

Phone: (205) 523-9300 Fax: (205) 523-9301 www.alabamaentspecialists.com

Craig M. Benoit, MD                                                    Gordon A. Shields, MD

I hereby authorized my insurance company, including Medicare if I am Medicare Beneficiary, to make payments to Alabama Ear, Nose & Throat Specialists, LLC (ALENTS) for medcal or surgical services or items rendered to me or my dependent by ALENTS. Should my insurance carrier deny ALENTS, I understand that I am financially responsible for the changes. I authorize ALENTS to release any and all of my records to my insurer, or any other third party payer, legally responsible for the payment of medical expenses. Should failure to pay for medical services result in my account being turned over for collection from a third party, or my insurer, I understand that I am responsible for the account balance plus reasonable collection and/or attorney’s fees. I certify that the information provided or to be provided by me is correct and complete to the best of my knowledge. It is my reponsibility to update any and all personal, insurance and health information.

302 Merchants Walk, Suite 100, Tuscaloosa, AL 35406

Phone: (205) 523-9300 Fax: (205) 523-9301 www.alabamaentspecialists.com

You have been given the Notice of Privacy Practices for Alabama Ear, Nose & Throat Specialists, LLC (AENTS) and its Physicians. This Notice describes your legal rights regarding your health information and will inform you of the legal duties and privacy practices of AENTS with respect to health information created for services generated by AENTS. If you receive services by your physician or their health care providers at a different location, you may want to ask about that office or clinic’s health information privacy policies and notices because they could be different.

Your name and signature below indicates that you have been provided with a copy of this Notice of Privacy Practices.

If you have a question regarding any of the information set forth in this Notice of Privacy Practices, please do not hesitate to call our Practice Administrator at (205) 523‐9300.

I authorize ALENTS and medical staff to discuss my healthcare information (which may include history, diagnosis, labs, test results, treatments and other health information) with the contracts listed below.

I understand that by leaving spaces blank I am indicating my choice to be a “No Information” and I do not want my information release to anyone else.

302 Merchants Walk, Suite 100, Tuscaloosa, AL 35406

Phone: (205) 523-9300 Fax: (205) 523-9301 www.alabamaentspecialists.com

In order to track Meaningful Use of our Electronic Medical Record, we are required to maintain the information below as part of your personal medical record.

As with all of your medical information, this will be maintained CONFIDENTIALLY.

*We will grant you access to our patient portal for electronic messaging and access to portions of your health record. We will NOT share your email address with any other parties.

302 Merchants Walk, Suite 100, Tuscaloosa, AL 35406

Phone: (205) 523-9300 Fax: (205) 523-9301 www.alabamaentspecialists.com