IN-OFFICE PROCEDURE CONSENT

The purpose of this form is to make you aware of a certain charge that may apply to your visits if you are complaining of sinus, ear, or throat problems.

If you are here for a consultation, follow-up, or post-op visit, it may be necessary for the doctor to do a certain procedure (Nasal Endoscopy, Laryngoscopy, Videostroboscopy,  Myringotomies, Debridements, Biopsies, etc.) in your evaluation and treatment.  According to The American Medical Association the procedures, Nasal Endoscopy, Laryngoscopy, etc. are classified as an in-office procedure/surgery.  Insurance companies sometimes apply these procedures/surgeries to your coinsurance and or deductible.  Therefore, after your claim is processed, you may receive a statement for the additional balance.  If you have any questions about your specific insurance plan benefit and your financial responsibility, please contact your insurance company direct.  Kindly indicate your understanding and consent of these procedures by signing below.