This organization strives to provide comprehensive, quality healthcare in the spirit of personal caring, safety and concern. To accomplish this goal, we believe that you, as our patient, and your significant other have the responsibility to make decisions regarding your healthcare and have the right to:

Patient Rights

As the patient/Caregiver, you have the RIGHT to:

Receive impartial access to treatment. We will provide treatment to our patients without regard to sex or cultural, economic, educational or religious backgrounds or source of payment.
Have cultural and personal values, beliefs and preferences respected.
Be treated by medical and non-medical staff with consideration, dignity and respect in a safe environment free from all forms of abuse, neglect, harassment and exploitation.
Examine and receive an explanation of your bill regardless of source of payment.
Receive treatment that is appropriate and complies with the standard of care in the community.
Receive reasonable continuity of care.
Be informed of continuing healthcare treatments and requirements.
Have knowledge of the name of the physician who has the primary responsibility for coordinating your care and the names of other physicians and non-physician staff who are involved in your treatment.
Seek a second opinion.
Be informed that all information concerning your medical care and records will be treated in a confidential manner. Written permission will be obtained from you or the person who has a legal responsibility to make decisions for you before medical records are released to anyone not directly related to and involved in your care.
Access information contained in your medical records within a reasonable time frame, including access to disclosures of protected health information in accordance with laws and regulations.
Receive a response to any reasonable request for service.
Receive an itemized explanation of charges.
Express grievances without fear of reprisal or discrimination.

Patient Responsibilities

As the patient or caregiver, you are RESPONSIBLE for:

Notifying the practice of change of address, phone number or insurance status.
Follow facility rules.
Participating in the plan of care/treatment.
Your actions if you do not follow the plan of care/treatment.
Notifying the practice of any change in condition, physician orders or primary/referring care physician.
Meeting the financial obligations of your health care as promptly as possible.
Providing accurate and complete information about present complaints, past illnesses, hospitalizations, medications and other matters pertinent to your health.
Treating others with respect.
Providing accurate and complete information about present complaints, past illness, hospitalization, medications and other matters pertinent to your health.

Practice Rights

As your provider of choice, we have the right to:

Terminate services to anyone who knowingly furnishes incorrect information to our company to secure services and equipment.
Refuse services to anyone who is threatening, intoxicated by alcohol, drugs and chemical substances or could potentially endanger our staff and patients.

PATIENT & FINANCIAL POLICIES

BECOMING A NEW PATIENT

Once accepted by the practice for a new patient appointment, new patients must complete the required forms prior to their appointment. These forms are available electronically on our website at www.carolinaearnosethroat.com or provided to you at check-in for your appointment.

Carolina Ear, Nose & Throat reserves the right to refuse acceptance of a new patient for operational, clinical, medical or financial reasons. Carolina Ear, Nose & Throat reserves the right to require ownership of a credit card and completion of a credit card authorization form as a condition for acceptance of a new patient.

Please note that in the unfortunate event a patient must be discharged from the care of a Carolina Ear, Nose & Throat provider, the patient is discharged from the entire practice and will be unable to receive medical care from any other Carolina Ear, Nose & Throat provider.

MAKING AN APPOINTMENT

Patients are seen on a scheduled basis. You may make an appointment through our website, your patient portal or by calling our office during regular office hours. Follow-up appointments also may be made during the check-out process following your completed appointment.

ARRIVAL FOR APPOINTMENT

It is Carolina Ear, Nose and Throat Sinus & Allergy Center’s policy to monitor and manage appointment no-shows, late cancellations and late appointments. The practice endeavors to provide excellent and timely care to each patient. If it is necessary to cancel an appointment, patients are required to call and speak with a practice representative or leave a message at least 24 hours prior to their appointment time. Appropriate notification allows the practice to better utilize appointments for other patients in need of medical care. Audio/Video recording of appointments is prohibited by parents, family members and staff.

NO SHOW/CANCELLATION AND LATE POLICY

No Show Policy:

A “No Show” shall mean any patient who fails to arrive for any scheduled appointment. Patients will be charged a fee of $50.00 for no-show appointments, including regular office visits (excluding allergy shots), and a fee of $100.00 for no-show appointments for: Special Testing. Special testing includes the following tests and procedures.

ABR/FNHS

Comprehensive Allergy Test

Comprehensive Allergy Test w/ Feno

ENG ENG/ECOG

Manometry

PH Probe

Thyroid Ultrasound

Tinnitus Eval

SLP

Patients who no-show for three appointments in a calendar year will be discharged from the practice.

Same Day Cancellation Policy:

A “Same Day Cancellation Policy shall mean any patient who cancels an appointment less than 24 hours before their scheduled appointment. Patients will be charged a fee of $50.00 for canceling without the appropriate notice. This fee will be collected before the appointment is rescheduled.

Late Arrival Policy:

A “Late Arrival” shall mean any patient who arrives at the clinic 15 minutes or more after the scheduled appointment time. Patients who are a “Late Arrival” to the clinic will have their scheduled healthcare professional for that visit determine the most appropriate course of action based on the patient’s individual clinical needs and the available practice resources.

PATIENT FINANCIAL POLICY

Payment of all current and outstanding patient balances is expected at the time of service, and we are required by your insurance plan to collect them. This includes copays, co-insurance, deductibles and previous outstanding balances. At a minimum, copays and any outstanding balance will need to be paid prior to seeing your physician. Estimated co-insurance and deductible amounts may be collected at the time of check-in and must be paid at check-out to the extent they can be determined at that time. If you are unable to make the required payment at time of service, your physician reserves the right to reschedule your appointment. If you are unable to make payments at the time of service, you will be directed to a patient account representative so that payment can be made. Repeated failure to make required payments will result in discharge from the practice.

INSURANCE

Our practice follows all insurance company-required rules. If we participate in your plan and you are eligible for benefits, we will file your charges with your insurance company.
Your insurance company requires we collect all patient payment responsibilities. Therefore, you will be expected to pay your co-payment, co-insurance and deductible amounts at the time services are rendered, or your appointment may be rescheduled. Additionally, patients will be responsible for non-covered services the patient approves.
In the event a lab, test or procedure is done, we will estimate your payment responsibility. You may be asked to pay your estimated payment at the time of your visit. Once your insurance has been paid, you will be billed or refunded any difference between what you paid and the amount due after the insurance payment.
If your insurance plan requires a referral or treatment authorization, it is ultimately your responsibility to ensure that the proper referral has been obtained. Any treatment without the necessary referral may result in a denial of payment by the insurance company, making payment for all charges your responsibility.

UNINSURED

If you do not have medical insurance, you will be responsible for a deposit payment of $300.00 plus any previous outstanding balance. If you cannot make this payment, your visit may be rescheduled.

MEDICARE

We are a participating provider with Medicare. As an added service, if you have coverage secondary to Medicare, we file that for you as well. Your co-insurance and deductible amounts will be due at the time of service, or your appointment may be rescheduled.

MEDICAID

We are a participating provider with North Carolina Medicaid; however, you must have your current card with you at the time of service. Your card must have a referral and remaining visits to be valid. We do not accept Out-of-State Medicaid.

WORKERS’COMPENSATION

We will file your workers’ compensation claim if we have authorization for the services. If there is no authorization on file, payment is due when services are rendered.

OVERDUE ACCOUNTS

We reserve the right to charge a fee for overdue accounts. If you need ongoing medical care, we expect payment on your old balance as well as payment in full for new charges at the time of service. Unresolved patient account balances will be turned over to a professional collections agency due to nonpayment, and you will be discharged from the practice.

ACKNOWLEDGEMENT OF RECEIPT OF PATIENT POLICIES & PATIENT FINANCIAL POLICY

I have read the Patient Policies and Patient Financial Policy and understand the policies.

I agree to pay at the time of visit all copays, coinsurance and deductibles due for the visit and to promptly pay all outstanding patient balances for services provided to me and my family. I understand that nonpayment of outstanding patient balances may result in discharge from care by the practice.

I understand that it is my responsibility to contact the practice to reschedule appointments as necessary at least 24 hours in advance of the scheduled appointment. I further understand that if I miss (“no-show”) three (3) scheduled appointments in a calendar year, I will be discharged from care by the practice.

All insurance payments for services rendered are assigned to this practice. (A copy of this assignment is as valid as the original).

I understand that it is my responsibility to understand my insurance company’s benefit policies as they may apply to services received from Carolina Ear, Nose & Throat, and to contact my insurance company to resolve any benefit payment concerns.

I understand that charges may occasionally be added or modified by my provider due to required corrections to services rendered or insurance claims billed.

I understand that I am financially responsible for all charges, whether or not they are covered by my insurance.

I authorize this practice to release to my insurance carrier any medical information needed to obtain payment for services rendered.

I understand that if I disagree with any charges, I will contact the practice in writing within 30 days of the billing date.

Should legal action be taken by the practice to collect an unpaid balance due for medical services provided, I agree to pay reasonable attorney’s fees or other such costs as the court determines proper.

NOTICE: Do not sign this agreement before you read and agree to the conditions set forth in the Patient Financial Policy. You should keep a copy of this agreement in your records.

Patient Rights & Responsibilities and Financial Policy