3075 Southwestern Blvd. (RT20), Suite 102 | Orchard Park, NY 14127
(716) 675-0616

Our Policies

Insurance Information
Patients are required to provide Southtowns Ear, Nose & Throat, LLP. their current insurance information each visit. Your failure to provide accurate insurance information may result in receiving a bill for which you will be responsible. Medicare recipients certify that the information given in applying for payment under Title XVIII of the Social Security Act is correct. We do not accept patients with Workers’ Compensation or No-fault cases.
Assignment of Benefits
By signing this agreement I request that payment of insurance benefits be made on my behalf to Southtowns Ear, Nose & Throat, LLP for any services provided. I authorize the release of any medical or other information necessary to determine the benefits payable by my insurance carrier, Social Security Administration or other medical entity.
Co-Payment/Co-Insurance
Patients will be required to pay at the time of service. By law we must collect your carrier designated copayments. Some insurance companies will have two copayments or co-insurance on the same date of service; if this applies you will be billed after it has been processed by your insurance. If you have a hearing test this is a separate provider and your insurance will process this according to your insurance coverage.
Deductibles
Patients who have a deductible will be required to pay $80.00 at the time of service. The amount is a deposit and other charges may occur once it has been processed by your insurance company.
Self-Pay
We will collect $80.00 at check-in. Surgery for self-pay will be collected prior to the procedure at 100% of the expected amount. All payments are a deposit and you billed for the remaining balance or refunded any overage. If you arrive for your visit and do not have payment at check-in you will be asked to reschedule.
Referrals
The patient must have a referral with an effective date when your insurance company requires it, or you will be asked to reschedule. It is your responsibility to make sure you obtain a referral and have it with you at the time of your visit.
Late Arrivals
We reserve the right to reschedule any patient who is 15 minutes late or more for their scheduled appointment.
Appointments
48 hour noticeem is expected if you cannot keep your appointment. Should you not provide this notice a cancellation fee of $50.00 may be added to your account.
Returned Checks
You will be charged $40.00 for a returned check.
Collection Agency
Southtowns Ear, Nose & Throat, LLP. patient balances that have not been paid in a timely manner may be turned over to a collection agency.
Surgery
It is the responsibility of the patient or responsible party to check on insurance benefits, and which facilities and/or anesthesia services are covered under your insurance. Our office will obtain surgical pre-authorization from the insurance company although this is not a guarantee of payment. Prior to having an operation the patient responsibility will be collected on an estimated price. All payments are a deposit, and the patient is billed any of the remaining balance or refunded any overage after the insurance portion has been received. If you need to cancel surgery for any reason you will be refunded any deposit minus the $45.00 cancellation fee.
In Office Procedures
Some procedures in the office, which are necessary for a complete evaluation, are in the Current Procedural Terminology (CPT) codebook under "surgery". This does not mean you had an operation. Please know that we have correctly performed and documented the services as required by the CPT coding guidelines. According to CPT guidelines, for example a fiber optic flexible larngoscopy, nasal endoscopy, or sinus debridement may be shown on your Explanation of Benefit form and processed as a surgical co-insurance or deductible.
Download our Financial Responsibility Statement PDF