To Better Serve You - What to Bring to an Appointment

Thank you for choosing the Ear Institute of Chicago! In order to best serve you and all of our patients, we ask the following to make your visit as smooth as possible:

New Patients

Please bring the following to your visit:

1. Patient Registration Form (form is editable on Mac or PC)
2. Patient Health History Form (form is editable on Mac or PC)
3. Consent for Treatment Form (form is editable on Mac or PC)
4. Privacy Acknowledgement Form (form is editable on Mac or PC)
5. Patient Communication Consent Form (form is editable on Mac or PC)
6. Patient Portal Proxy Access Form (form is editable on Mac or PC)
7. Your insurance card
8. Photo ID
9. List of medications you are taking currently
10. Hearing evaluations (audiograms) and CD’s of CT or MRI films pertinent to your visit
11. Written approval of your referral (if required by your insurance)

Established Patients

Please bring the following to your visit:

1. Your insurance card
2. Photo ID
3. Hearing evaluations (audiograms) and CD’s of CT or MRI films pertinent to your visit
4. Written approval of your referral (if required by your insurance)

New AND Established Patients

• Keep all of your scheduled appointments. If you need to cancel / reschedule your visit, please do so 24 HOURS PRIOR TO your appointment.
• Notify our front desk staff of any changes in your address, contact phone numbers, insurance or name changes prior to seeing the physicians. When these are incorrect it is more likely your bill will not be paid by your insurance company.
• Your appointment will be confirmed by our automated system that calls to inform you as a reminder of the appointment date, time.
• Please come 15 minutes early for the appointment to allow for entry of your personal information and insurance information into our computerized system.

Your Financial Responsibility

Our office participates with many different types of insurance. We will bill your insurance for services, but ultimately you are responsible for paying for any services received in our office. You are responsible for paying the co-pay at time of service. You have agreed to this co-pay with your insurance company.
Unfortunately, not all services are paid for by the insurance company. In cases where the service is not paid, you will be responsible for payment. We will bill your insurance company first and make sure that all the information sent to the insurance company is accurate and clearly describes any services that you received.
The Federal Law requires us to submit all claims to an insurance company accurately and report the exact service that is performed and why the service was performed. We are not allowed to change this information just so that the insurance company will pay the claim.
If you do not have insurance we require full payment of services at time of the visit. A payment plan may be possible. We accept Discover, Visa, and MasterCard and participate with Care Credit as a method of payment for services. A discount is offered for all services if full payment is made on day of service.

Covered or Non-Covered Services

It is always best to double check with your insurance company if you are unsure whether you need a referral, services are covered, not covered or if there is a deductible. It is best you know your insurance coverage before your appointment. You may call the number on the back of your insurance card to find out any information with which you are unaware. The Ear Institute of Chicago may not be aware of your specific insurance coverage.

What About a Referral?

It is your responsibility to know the requirements from your insurance company on the need for a referral or authorization at time of visit. Because we are specialists, a referral may be necessary. We may not be able to see you if we do not have the proper referral or authorization. Many insurances, including HMOs, require a referral to a specialist prior to the visit.
Referrals are obtained from your Primary Care Physician. Please give your Primary Care Physician at least 10 days notice of your need for a referral, except when it is an emergency. The paperwork may be faxed to our office for the visit (630-789-6219). Verify prior to your visit if you have a question about our receiving the referral.
Your referral should authorize any services that may be performed by the physician as well as any testing that may be necessary or indicated, such as a hearing test, by our audiologists.
If we do not have your referral, you may be financially responsible for the cost of the visit and will be required to pay for the services in full until the referral is obtained.