Self pay OON Authorization

Authorization for use of
Self-Pay or Out of Network Benefits

Notice to Insured Patients with OON Benefits:

Prime ENT Sinus, Sleep & Allergy is currently out of network with your insurance. If your policy allows, you may self-pay or use your out of network benefits for your care at Prime ENT. If you use your 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 insurance benefits.

I will use my out of network benefits with my insurance

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 insurance out of network deductible.

I understand that the claim for my care will be billed to my insurance 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 my insurance carrier.

We are sorry we will be unable to care for you.

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)

Insurance ID Number(Required)

Authorization for use ofSelf-Pay or Out of Network Benefits

Authorization for use of
Self-Pay or Out of Network Benefits