Ear Institute of Chicago, LLC Insurance and Payment Policy

EAR INSTITUTE OF CHICAGO, LLC

Insurance and Payment Policy

The following are insurance/payment issues that may apply to you as a patient of The Ear Institute of Chicago, LLC:

If we do not have confirmation of your insurance coverage either by a current insurance card or letter of eligibility from your insurance company or employer, you, the patient, are responsible for any charges incurred at the time of your visit. This remains in effect until such time this information is received by the office. Your co-pay and/or any outstanding balance is due when you check-in unless other financial arrangements are made.

Many insurance companies do not cover preventive medicine or screening tests, (for example, hearing tests [also known as an audiogram]) even though your physician may find it necessary. If this is the case and you agree to proceed with these services, you are responsible for payment.

If your insurance company does not cover certain services deemed necessary by your physician and you agree to proceed with these services, you are responsible for payment.

It is your responsibility as the patient to know if your physician is “in network” or if a referral is required.

If your account becomes delinquent and is turned over to a collection agency, you will be responsible for the unpaid balance and any collection agency fees incurred. You will not be seen in our office until all balances are paid unless a physician of the Ear Institute of Chicago, LLC determines that your condition is either medically emergent or urgent.

I have read and understand the above statements and accept liability for all services rendered.

Patient Name (print): _______________________________________________________________________

Patient Signature: __________________________________________________________________________

Witness Signature: _________________________________________________________________________

Date: _________________________________________