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New Patient

Step 1 of 2

50%
  • Patient Information

  • Emergency Contact

  • Responsible Party Information

  • Date Format: MM slash DD slash YYYY
  • Insurance Information

  • Insurance Authorization and Assignment

    I request that payment of authorized Medicare/ Other Insurance Company benefits be made to Valley Ear, Nose and Throat Associates, P.C. for any services furnished to me. I authorize any holder of medical information about me to release to Health Care Financing Administration and its agents any information needed to determine these benefits payable to related services. I understand that the patient is responsible only for the deductible, coinsurance, and non-covered services. I requested that the above remain in effect until written notice is received from me.
  • Date Format: MM slash DD slash YYYY