Patient Forms for Lend Me Your Ear

Thank you for booking an appointment.

If you are a new patient, please complete and bring the new patient forms to your first visit. If you are an existing patient and need to update your information, please bring the update forms.

 

We look forward to seeing you!   

Important Insurance Information Acknowledgement:

 

Bring a photo ID and insurance cards to your appointment.

If your insurance requires a referral, bring physicians referral to appointment. Medicare and all HMO policies require physician referral prior to your appointment for insurance coverage.

If your insurance requires a referral and you do not bring the physicians referral all services will be considered private pay. It is the responsibility of the patient to obtain a copy of the referral prior to the appointment. All Dr. referrals can be faxed to 432-262-1851.

 

We are in-network with Medicare.

       Medicare will only pay for a medical necessary hearing test with Dr. Referral. Medicare will not pay for medical unnecessary testing/services, cerumen           removal, and any hearing aid services.

 

We are in-network with BlueCross BlueShield.

       Most PPO policies do not require a physician referral for services unless otherwise stated in your individual insurance policy.

       HMO policies do require your primary physician to submit a referral for hearing services to BlueCross and BlueShield prior to services rendered for any         insurance coverage.

 

We are out of network with all other insurance policies including United Healthcare, Cigna, and Aetna.

      Most PPO policies do not require a physician referral for services unless otherwise stated in your individual insurance policy.

 

Payment in full is due at time services are rendered.