Thank you for choosing Panhandle Ear, Nose & Throat as your Trusted Health Care Partner. In order to better serve your needs, we have a New Patient Packet for your completion.
Please complete the following forms:
Patient Information – please complete all sections on the front and back, making sure to sign and date all areas. Make sure to bring all your insurance cards; we will need to make copies.
Patient Family History – Two pages – please complete both pages.
Patient Payment Policy – Three pages, the Patient Payment Policy is yours to read and keep. Please complete, sign and date the Patient Payment Policy Acknowledgment form.
Patient Notice of Privacy Policies – HIPAA Notice of Privacy Practices and an Acknowledgment of Receipt of Notice of Privacy Practices – Two pages, the Notice of Privacy Practices is yours to read and keep. Please complete, sign and date the Acknowledgment of Receipt of Notice of Privacy Practices Acknowledgment form.
BSA Consent for Treatment – Two pages Please complete, sign and date both pages of the BSA Consent for Treatment form.
Red Flags mandate – The Federal Trade Commission put the “Red Flags” mandate in effect on August 1, 2009. This mandate requires all physician offices to obtain a photo ID on all patients. Therefore, we will be asking for a photo ID. A driver license may be used for an adult patient. The parent’s driver’s license may be used as ID for a child. If you do not have a photo ID, we will need an additional form of ID; this can include a passport, military ID or other state or federal form of ID. This mandate was put into place to help protect your medical and financial identification.
Please arrive at the office 20 minutes before your appointment time with your completed packet, your photo ID and your insurance cards.
If you have any questions, please feel free to call. You can reach us by calling (806) 355-5625 and selecting option 1.