OHIO EAR INSTITUTE , LLC

The following are insurance/payment issues that may apply to you as a patient of the Ohio Ear Institute, 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 this office.

• Many insurance companies do not cover preventive medicine or screening tests
(audiograms, i.e. hearing tests) even though your physician may find it necessary.
If this is the case and you agree to proceed with this test, 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 to know what your insurance company will cover.

• It is your responsibility as the patient to know if your physician is “in network.”

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

Patient Name: ______________________________________________________

Signature: ______________________________________________________

Witness Signature: ________________________________________________

Date of Notice: ________________________________________________