About Your Visit

Thank you for choosing Potomac Otolaryngology as your ENT provider.

We are committed to providing you with quality and affordable health care! In order to process your visit more efficiently and get you into your appointment more quickly, please arrive 20 minutes prior to your scheduled appointment time if you have not filled out your medical history forms ahead of time. If you have reviewed and completed the forms ahead of time, please arrive 5-10 minutes prior to your scheduled appointment time. The complete Registration Packet can be found below under “Patient Forms”.

The registration packet must be completed before your appointment. Please bring a valid ID and your insurance card.

• Patient Authorization Form
• Registration Form and Financial Policy
• Notice of Privacy Practices
• Allergy Forms Packet
• Non-Parental Consent to Medical/Surgical Care and Treatment
• Medical Records REQUEST Form
• ABR/ECOG Patient Form
• VNG Patient Form

Thank you for choosing us as your ENT provider. We are committed to providing you with quality and affordable health care. In an effort to answer all of your billing and insurance payment questions we have developed this payment policy. Please read it, ask us any questions you may have, and sign in the space provided. A copy will be provided to you upon request. All co-payments, co-insurance, and deductibles will be collected at time of service.

We participate with most insurance plans, including Medicare and Medicaid. Knowing your insurance benefits and providing us with an up-to-date insurance card and a referral if required is your responsibility. Please contact your insurance company if you have any questions regarding coverage. If you are not insured by an insurance plan we do offer a self-pay option, payment in full is expected at each visit. If you are insured by a plan but we do not have an up-to-date insurance card with you, payment in full is expected at each visit until we can verify your coverage.

Please be aware that some – and perhaps all – of the services you receive may be noncovered or not considered reasonable or medically necessary by Medicare/Medicaid or other insurers. Noncovered services are required to be paid in full at the time of service.

All patients must complete our patient information form before seeing the doctor. We must obtain a copy of your driver’s license and current valid insurance card to provide proof of insurance. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the balance of a claim.

We will submit your claims and assist you in any way we reasonable can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company; we are not a party to that contract.

If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits. If your insurance company does not pay your claim in 90 days, the balance will automatically be billed to you.

If your account is over 90 days past due and all attempts to arrange payment have failed, please be aware we may refer your account to a collection agency and you may be discharged from this practice. Partial payments will not be accepted unless otherwise negotiated. You may not be seen in the office until the balance has been paid full. Partial payments will not be accepted unless otherwise negotiated. Please be aware that if a balance remains unpaid, we may refer your account to a collection agency and you may be discharged from this practice. If this is to occur, you will be notified by regular and certified mail that you have 30 days to find alternative medical care. During that 30-day period, our physician will only be able to treat you on an emergency basis.

Our policy is to charge $50.00 for missed appointments canceled less than 48 hours in advance. Failure to cancel VNG/ECOG/ABR appointments in 72 hours will result in a charge of $150.00. Surgery appointments must be canceled 2 weeks in advance otherwise there will be a charge of $150.00. These charges will be your responsibility and billed directly to you. Please help us to serve you better by keeping your regularly schedule appointment.s

There is a $35.00 fee for checks that are returned due to insufficient funds.

Our practice is committed to providing you with quality patient care. Our prices are representative of the usual and customary charges for our area. Thank you for understanding our payment policy. Please let us know if you have any questions or concerns.

• Aetna – (Not Aetna Better Health)
• Aetna Innovation EPO
• Anthem BCBS
• Anthem Healthkeepers Plus
• ASI
• BCBS Federal Employee Program
• Carefirst BCBS
• Cigna – (Not Cigna Connect)
• Core Source
• Coventry Health Services
• Empire BCBS
• Golden Rule
• Highmark Medicare Services
• Horizon Blue Cross of NJ
• Humana
• Medicaid Virginia
• Medicare Virginia
• Onenet PPO
• Optimahealth
• Pomco
• Railroad Medicare
• Tricare
• UMR
• VA Premier