Ear Nose Throat Specialists, PC -  -  - Dr. Goldberg - New Patients -
See Dr. Goldberg’s profile on Healthgrades.


Location

723 Fitzwatertown Road Willow Grove, PA 19090

Call Us

(215) 659-8805

New Patients

To help make your first visit to our practice as smooth as possible, please read the information on this web page. You’ll find all the practical information you need, such as a map and directions to our office, practice hours, payment policies and more. We also describe our first visit procedures. And, you can save some time by printing out and completing the new patient forms in advance of your appointment.

Mission Statement

Our practice is working together to realize a shared vision of uncompromising excellence in medical care.

To fulfill this mission, we are committed to:

  • Listening to those we are privileged to serve.
  • Earn the trust and respect of patients, profession and community.
  • Exceed your expectations.
  • Ensure a creative, challenging and compassionate professional environment.
  • Strive for continuous improvement at all levels.

Ear Nose Throat & Facial Plastic Surgery Specialists, PC

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For appointments not kept or cancelled less than 24 hours peior to your appointment date & time, the full charge of the visit, diagnostic testing, procedure, and or surgical procedure, will be charged to you.

Insurance Information

If insurance is held by someone other than the patient, please fill out the information below:
 
 

Patient Financial Responsibility Information

Thank you for choosing us as your health care provider. the following is our financial policy. Our main concern is that you receive the proper and optimal treatments needed to restore your healht. Therfore, if you have any questions or concerns about our payment policies, please do not hesitate to contact our billing department.

We ask that all patients read and sign our financial policy and HIPAA form as well as complete our patient information form & consent form prior to having your examination, therapy, and/or study. Medicare patients are required to sign an ABN.

All insured patients are required to sign the assignment of benefits for payment from the insurance company. We will submit your claim to the insurance company on your behalf but if the insurance company does not pay your balance in full within 30 days, we ask that you contact the carrier. You will be billed for any con-covered services, deductibles, co-pays, and/or co-insurance & finance charges.

It is the responsibility of the patient to ensure any referrals, precertification, or authorizations have been obtained prior to your appointment. In the event your planned procedures are not followed prior to your appointment, your appointment may be rescheduled.

Delinquent accounts will be turned over to collection agency with a 2 week notice unless demographic information has changed and returned to us by the United States postal service. Account will be considered delinquent if unpaid after 60 days. In the event your account is turned over to collection, you will be responsible for all reasonable collection and court costs at the time the account is considered delinquent. Again, thank you for choosing us as your health care provider. We appreciate the opportunity to serve you.

The office of Dr.Goldberg may have ordered a study, test, consultation and/or followup appointment for you. We will assume if you have not scheduled the advised order that you do not plan on having the above performed. Missing followup may be subject to misdiagnosis, delayed diagnosis & maltreatment.

Please advice us if there has been a change in your address, phone number, or insurance coverage since your last appointment.

If you are unable to keep your appointment with the Doctor and do not give 24 hours notice a fee may be charged.

If you unable to keep your procedure or testing appointment and do not give 48 hours notice a fee may be charged.

Payment is expected as services are rendered unless prior financial arrangements have been made.

If co-pay is not paid at the time of the visit, there will be a charge of $11.50 for adminsistrative costs.

A Fee of $25.00 will be charged for all returned checks.

There will be an administrative fee for the completion of all forms.

 
 
 

Social History

 

REVIEW OF SYSTEMS

 
 

Questions

If you have any questions about this notice please contact our privacy official at the office address and number.

Privacy Official
You may contact our privacy official at 723 Fitzwatertown Road, Willow Grove, PA 19090
Phone: (215)659-8805

I acknowledge that a copy of this notice of privacy practices for Ear Nose Throat & Facial Plastic Surgery Specialists PC was made available to me.

If i wish to allow a family member or a friend to receive my personal protected health information, I must sign an authorization form provided by the practice.

 
 

Office Billing Policies

Welcome to the Practice. We are so happy that you chose our practice to help you with your Ear Nose Throat, ENT Allergy, Facial Plastic & Hearing Aids.

It is your responsibility to know if your insurance plan requires you to have a referral at the time of youroffice visit. If a referral is required, it is expected that we receive it no later than the date of your visit. It is the patient's responsibility to request and manage their referral.

Your co-payment is required to be collected on the day services are rendered. As a convenience, our practice accepts Cash, Checks & Credit cards. If a check is returned by the bank for non-sufficient fund, a service charge of $25 will be incurred to cover bank fees.

If you insurance plan has a deductible in its policy, you will be required to pay for any costs deemed to be patient responsibility. If you have any questions regarding your insurance policy contact you insurance company and/or any member of our front desk staff. Finance charges will accrue on patient responsibility balances greater than 60 days.

We participate with the Medicare program. To those patients who do not have a secondary insurance please realize that you are responsible for paying the deductible and 20% of the accepted fee that Medicare allows.

You must understand that certain tests, scopes, treatments, surgeries and/or procedures are required to be paid completely if your insurance policy or insurance company does not.

Patients who DO NOT have any insurance or have an insurance plan that we do not participate, are expected to pay for the visit or procedure before leaving the office. Please ask the front desk for the costs that will be associated with your office visit. If a specimen is sent to the lab for pathology you will incur additional charges billed to you by the lab.

If it is necessary to cancel an appointment, we require that 25 hour notice be given. if 24 hour notice is not provided, $50 will be billed for missed office appointments. $300 will be billed for missed allergy skin tests. $500 will be billed for missed Otologic/Vestibular testing. $600 will be billed for missed surgeries and office procedures.

I AUTHORIZE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO MANAGE MY CARE.
I UNDERSTAND AND AGREE THAT REGARDLESS OF MY INSURANCE STATUS, I AM ULTIMATELY RESPONSIBLE FOR THE BALANCE ON MY ACCOUNT FOR ANY PROFESSIONAL SERVICE RENDERED. I HAVE COMPLETED THE ABOVE QUESTIONS AND CERTIFY THIS INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. I WILL NOTIFY YOU OF ANY CHANGES IN MY INSURANCE STATUS OR ANY OF THE ABOVE INFORMATION. I AUTHORIZE THE STAFF TO PERFORM ALL NECESSARY SERVICES NEEDED DURING THE DIAGNOSIS AND TREATMENT. I ALSO AUTHORIZE THE PROVIDER TO RELEASE ALL INFORMATION REQUIRED TO PROCESS INSURANCE CLAIMS.

What to Expect

Being well-prepared for your appointment will ensure that the doctor has all of the needed information to provide the best possible care for you. It also will help relieve any unnecessary anxiety you may be feeling. Educate yourself on your symptoms by reviewing the content on this Web site. Also, take some time to review our staff page and familiarize yourself with the doctors. We look forward to your first visit.

New Patients Forms

You can also print and fill out this form so we can expedite your first visit