Patient Forms

Forms can be completed online through the patient portal or you can print them from our website and bring them with you to your appointment.

Insurance & Fees

Policies, Insurance, and Billing

There are a few policies to be aware of when being seen at Winchester ENT:

  • Payment is required at the close of the appointment.
  • Copays are due prior to being seen, patient will not be seen without paying copays if their insurance requires them.
  • Our office submits claims electronically and may know your patient responsibility balance prior to you receiving a statement. Our office reserves the right to update you based on your insurance’s payment and your patient responsibility. We may ask while you are in our office to pay on your account.
  • 24 hr confirmation calls, email and text reminders will be made to remind you of your appointment. If you fail to show for your appointment and do not give 24hr notification a $25 fee will be charged to your account and you will not be able to be seen until it is paid. If you are scheduled with the Audiologist an additional $50 charge will be assessed.
  • If you no show for an office surgical procedure and do not call before 24hrs you will be charged $50. If you are a no show for a hospital surgery and fail to cancel within 24 hrs a $155 fee will be charged.
  • All hospital surgery cancellations require a minimum 5 day business notification and failure to notify office in sufficient time will result in a $155.00 fee charge.
  • Failure to pay your balance in full in 30 days will be subject to finance charge. Failure to pay your balance within 90 days will result in your account being turned over to collections. We will attempt to communicate with your insurance; however, it is ultimately the patient’s responsibility for all fees incurred.
  • Patients without insurance will be required to pay a $160 prior to being seen. This may or may not cover full charges. You will be required to pay the balance at your exit. Before procedures are performed you will be informed of the price.
  • Prescriptions will be given at the time of your appointment. The office will not call in or fax in refill prescriptions without a patient being seen. Please remember to ask for any refill at the time of your visit.
  • Returned Bank Check charge is $25.00.
  • All current balances must be paid in full prior to the scheduling of a surgical procedure. Our office also reserves the right to collect half the patient’s out of pocket expense prior to the scheduling of any procedure.