ALABAMA EAR, NOSE & THROAT SPECIALISTS, LLC

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

Please Check the Appropriate Boxes If You Are Experiencing Any of the Following Symptoms:

I hereby authorize my insurance company, including Medicare if I am a Medicare Beneficiary, to make payments to Alabama Ear, Nose & Throat Specialists, LLC (ALENTS) for medical 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 charges. 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 responsibility to update any and all personal, insurance and health information.

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 other 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 contacts 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 released to anyone else.

Thank you for choosing Alabama Ear, Nose & Throat Specialists.

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.