Southwest FL Center for Hearing and Balance New Patient Form

New Patient Form
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Financial Policy Form
Thank you for choosing us to care for your hearing and balance needs. We are committed to your better hearing and resolution of your balance problems. Please understand that in order for us to maintain the highest level of care, payment must be received. Payment is considered part of your service. Due to the personnel resources and time commitment needed to provide the complex services offered, it is imperative that our patients be very faithful in keeping their scheduled appointments. We understand that unforeseen events occur that require last minute cancellations of appointments. However, our small center cannot be expected to bear the financial loss that occurs when this reserved appointment time goes unutilized. If you make an appointment and are unable to attend, if we are not notified 24 hours prior to that appointment a $50 fee will be assessed.

Sometimes offices offer “Free Hearing Tests”. In general, free hearing tests are not really free; instead they are a lure to invite you into their offices so that they may sell you hearing aids. In many cases the evaluation is not complete enough to fit you with hearing aids and is only finished once you have committed to the purchase. If the test is complete, the cost of the test is wrapped up in the price of the devices you purchase. At Southwest Florida Center for Hearing and Balance we believe that the diagnostic tests we provide are of value in and of themselves whether you decide to follow our rehabilitation recommendations or not. We believe that the doctoral degree our clinicians hold affords our patients accurate, reliable diagnostic data followed by insightful interpretation and honest rehabilitation recommendations. A charge will be assessed for any diagnostic procedure or service we perform.

All patients must complete our information sheet and provide us with updated insurance information if applicable. We will accept assignment of many insurance benefits. However, we do require that any copays or deductibles be paid at the time of service. The balance is your responsibility whether your insurance company pays or not. Your insurance policy is a contract between you and your insurance company. We are not a party to that contract. We accept cash, checks, VISA, MasterCard, Discover and American Express. With an increase in insurance plans as well policy and copay variations it is sometimes impossible for us to collect all the amount due at the time of service. As a result if we are filing your insurance, we will require a credit card to be on file, stored securely through a third party. Once your insurance has processed the claim and there is a balance due, we will send you an invoice via email. If this invoice is not paid within 5 days, we will automatically charge the balance due to your credit card on file. This in now way hinders your ability to appeal your insurance company’s decision. If they determine the amount due is incorrect we will promptly refund this amount to your account once we receive the monies from the insurance company.

MEDICARE (and most insurance companies) will pay for an initial hearing evaluation, a cochlear implant evaluation, mapping or testing, Auditory Brainstem Response (ABR) and ECoG (Electrocochleography) once per year and when medically necessary without a physician referral. Balance testing including Videonystagmography (VNG), Vestibular Evoked Myogenic Potentials (VEMP) must be medically necessary AND referred by a physician. If your visit meets these criteria, we can expect payment will be made through your insurance company. We will do our best to keep you informed if we expect your visit may not be covered.

Medicare and many insurance companies do not cover a routine hearing exam annually, though your audiologist may recommend you have an evaluation to determine the current status of your hearing and to verify the current settings on your hearing aids are appropriate. In addition, if you are purchasing a hearing aid and an evaluation has not been completed within 6 months, Florida Law requires a new hearing exam to be completed within 6 months of being fitted with new hearing aids. Therefore, if your exam is an annual exam, prescheduled after your hearing aids have been fit, or for the purpose of a new hearing aid fitting, you will be expected to pay at the time of service. The cost for a hearing exam is $128.75. Many Medicare Advantage programs will cover an annual hearing evaluation. If this is the case we will bill your insurance and expect payment from them.

Medicare and many insurances also do not cover wax removal by an audiologist nor do they cover treatment for BPPV when performed by an audiologist, even though these things are well within the scope of an audiologist’s practice. As a result if you proceed with either of these procedures you will incur an out of pocket expenses, $89 for wax removal and $118.45 for BPPV treatment. Your doctor will advise you if this is recommended and obtain your consent before doing any treatment.

Not all cochlear implant services are covered by insurances; specifically, troubleshooting and counseling, and instruction on how to use the device or its wireless components. Non reimbursed cochlear implant services will be charged $66.95 for each 15 minute segment of service.

Thank you for understanding our Financial Position and Policy. Please let us know if you have questions or concerns.
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Beginning August 15, 2024, we are implementing a policy requiring that a credit card be held securely on file for each of our patients for whom we will be billing their insurance.

As you may know, the healthcare field has experienced some dramatic changes over the past few years and gone are the days of health insurance picking up the tab for all medical expenses. The result is increased patient deductibles, copays, and co-insurance. To make payment more convenient for you, as well as to keep our billing costs down, we have put into place a credit card on file program.

Here’s how it works:

1.    To keep your information safe and secure, we’re partnering with an off-site, third-party company that will securely store your credit card, debit card, or health reimbursement card (HSA/FSA) information.

2.    When you come in for your next appointment and we are billing your insurance, you will complete an authorization form. We will then set up the card with the third-party company.

3.    It will be on file only for future use. We will submit your claim to your insurance company, and they will process the claim and send us and you an Explanation of Benefits. This will show what they covered and what your responsibility is.

4.    Our practice will then send you an email invoice. If the payment has not been made in 5 business days, we will charge your credit card, debit card, or health reimbursement card for the remaining balance. We will email you a receipt.

Rest assured, this program in no way hinders your ability to dispute a charge or question your insurance company about their determination of payment. If a determination is made that the insurance company’s initial notification of amount due changes, the appropriate amount will be credited to your account and refunded to the card on file.

Thank you in advance for your understanding and cooperation with this new program. And we look forward to continuing to meet your hearing and balance needs with the best care possible.

I have read and understand the Securely Held Credit Card Policy.
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Authorization for Special Tests
In recent years evidence has been accumulating linking age-related hearing loss to more rapid progression of cognitive decline, and therefore incidental dementia. Long term hearing deprivation (hearing loss that is left untreated) can impact cognitive performance by decreasing quality of communication. Hearing loss makes it difficult to understand speech, particularly in noisy environments. Often this leads to social isolation, anxiety and depression which can accelerate the onset of dementia.   There are many factors that impact cognition and overall wellness, but the good news is you can take steps to manage these risk factors!

We offer two screenings that are not covered by insurance but are essential to an accurate diagnosis and treatment plan for each patient! These include a brain health screening and a speech in noise test. We recommend that ALL our patients over the age of 50 have these screenings to help us create your best, most customized plan going forward. It is also a good idea to have a baseline for these screenings even if you aren’t yet 50.

The cognitive screening is a 5–10 minute self-administered test that evaluates your memory, visuospatial skills, and executive function. The speech in noise test is performed with the audiologist and allows us to identify if your auditory system functions well or poorly, when presented with more challenging listening   environments.

We offer each screening alone or a bundled option.

Both screenings $60

Quick SIN Speech in Noise Test $15.45

Cognivue cognitive screening $46.35
I would like to have BOTH testsI would like to have ONLY the speech in noise test.I would like to have ONLY the cognitive screening.I Decline BOTH tests.

Notice of Privacy Practices
SUMMARY OF HOW WE WILL USE YOUR INFORMATION

We will potentially use your information in 4 different ways:

1. We are obligated to share your condition and findings with the physician who referred you. If no physician referred you we will only share it with a physician if you make this request.

2. We will share the tests we did, our office notes and/or your diagnosis with your insurance company so that they will pay your claim.

3. We will discuss your case with any person to whom you have given your permission to share it.

4. We will invite you to share your experience at our office. You may receive an email requesting feedback.

If you would like to read the full text of our privacy notice, please use the QR code below to access the document.
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New Patient Form

ABOUT YOUR EARS:

ABOUT YOUR HEARING:

Medical History

Financial Policy Form

Authorization for Special Tests

Notice of Privacy Practices