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Forms & Information

For shorter wait times, please complete and bring the appropriate forms to your first appointment.

Please indicate “N/A” or “None” when a section does not apply to you.

NEW PATIENT FORMS

GENERAL FORMS

INFORMATION TO HAVE ON HAND:

Be advised, if any of the required information listed below is missing it may be necessary to reschedule your appointment until it is available to you.

  • Insurance card(s)
  • Valid driver’s license or government-issued photo ID
  • Insurance policyholder information — this is the person who holds the policy under which you are covered.
    • Policy holder’s name
    • Social security number
    • Date of birth
    • Name of policy holder’s employer (if applicable)

COPAYS & DEDUCTIBLES:

  • Please be aware of your insurance co-pay, deductible, and coinsurance.
  • Specialist co-pays may not cover all diagnostic services performed in the office.  Please contact your insurance carrier to determine individual benefits.

All co-pays, deductibles, and coinsurances are collected at the time of your visit with no exceptions!

INSURANCE AUTHORIZATION:

  • Obtain an authorization or referral if required by your insurance. Please contact your insurance company or primary care physician for more information.

MEDICAL RECORDS:

  • Bring any pertinent medical records pertaining to your visit such as scans or test results. This is helpful to diagnose and treat your condition.

Request An Appointment

  • For appointment scheduling only. Please DO NOT submit medical questions or general correspondence.

Office Locations

Clearwater
Countryside
Dunedin
Largo
Facial Aesthetics Center
Port Richey
St. Petersburg
Tampa
Trinity


Contact Us

ENT Associates Main Office

Address:
1330 South Fort Harrison
Clearwater, FL 33756

Phone: 727-441-3588
Fax: 727-461-1038

Hours of Business: 8:00AM - 5:00PM

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Copyright 2016 ENT Associates