Blue Shield Authorization

Blue Shield Authorization
Self Pay/Out of Network Benefits

Notice to Blue Shield Patients:

Prime ENT Sinus, Sleep & Allergy is currently out of network with Blue Shield California. If you are a member of Blue Shield of California, you may self-pay or use your out of network benefits for your care at Prime ENT. If you use your Blue Shield insurance, the copays, deductibles and co-insurance will follow the out of network fee schedule.

As we absolutely wish to be transparent with our patients, please note the estimated fees for our most common services:

New patient consultation office visit $250 - $300

Established patient office visit $150 - $200

Procedures (additional charges to office visit fees): Nasal Endoscopy - $210 Ear Wax Removal - $50 - $100

If you have not met your out of network deductible amount, you may be responsible for the cost of services performed at Prime ENT.

After reviewing the above information, please select one of the following options:(Required)

I choose to self-pay and not use my Blue Cross/Blue Shield benefits.

I will use my out of network benefits with Blue Shield

Please cancel my appointment(s). I will find care with an in-network provider

Please note, amounts paid in this manner will not apply or be reflected in your Blue Cross/Blue Shield out of network deductible.

I understand that the claim for my care will be billed to Blue Cross/Blue Shield of California as out of network charges. I agree that I will pay the estimated patient responsibility balance at the time of my appointment and agree to be billed for any remaining balance after the claim has been processed by Blue Shield of California.

We are sorry we will be unable to care for you. Please use this link to find a provider contracted with your insurance plan: https://www.blueshieldca.com/fad/home

Patient Name(Required)

First Last

Is the patient under the age of 18?(Required)

Yes

Name of Parent/Insured

First Last

Patient Date of Birth(Required)

Blue Shield Member's ID Number(Required)

Prime ENT has repeatedly applied to Blue Shield California to be added as a contracted provider so that we may serve our patient community in the most cost-effective manner. However, Blue Shield has declined to consider adding any additional specialty providers in San Joaquin and Stanislaw counties, limiting their members options in seeking convenient and quality care. If you find this limiting of care options unacceptable, please consider calling Blue Shield Customer Service using the number on the back of your insurance card and emailing your employer benefits/HR department. We appreciate your support and hope to resolve this matter with Blue Shield as soon as possible to best serve our community.

Blue Shield Authorization Self Pay/Out of Network Benefits

Blue Shield Authorization
Self Pay/Out of Network Benefits