If you have not visited us yet, please fill out the following packet and bring it in when you come for your appointment. Please be sure to come 15 minutes early.
To save you time at check-in, we request that you complete the New Patient Packet beforehand.
Documents personal and insurance information.
Documents your list of medications, surgeries, allergies, etc.
Documents how Glacier Ear, Nose & Throat is required to keep our patient’s information and medical records private.
Allows Glacier Ear, Nose, & Throat permission to speak with a member of your family or a friend about your medical and billing information.
Documents Glacier Ear, Nose, & Throat’s financial agreement with our patients.
Allows the patient to authorize the release of their medical information to be sent to Glacier Ear, Nose & Throat.
A form to be used by patients to secure a referral for a hearing test from their primary provider.
Allows the patient to authorize the release of their medical information from Glacier Ear, Nose & Throat.
Authorizes Glacier Ear, Nose & Throat to set up regular credit card payments on patient accounts. Prior authorization with our Billing Department is required for use of this program.