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Patient Forms

The forms listed here can either be downloaded and completed online or completed manually.

By offering these forms to you in advance, you will be able to complete them at your own pace and in the comfort of your own home. It also helps our office reach the goal of serving our patients more efficiently at their appointment time.

New Patients

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.

New Patient Packet

*Note: Included in this packet are 4 pages that require filling circles, which we refer to as “Patient History” forms. This packet contains copies of these 4 pages and we require that the originals be completed at your check-in time. To save you time at check-in, we request that you complete the copies beforehand, bring them with you to your visit and transfer your answers once you are here.

Individual Forms

Patient Information Sheet

Documents personal and insurance information.

Patient Health History

Documents your list of medications, surgeries, allergies, ect.

Comprehensive Patient Health History

Provides detailed medical, social, and financial information to assist the physician in the diagnosis process.

Notice of Privacy Practices

Documents how Glacier Ear, Nose & Throat is required to keep our patient’s information and medical records private.

Permission to Disclose

Allows Glacier Ear, Nose, & Throat permission to speak with a member of your family or a friend about your medical and billing information.

Financial Policy

Documents Glacier Ear, Nose, & Throat’s financial agreement with our patients.

Authorization to release medical information to glacier ent

Allows the patient to authorize the release of their medical information to be sent to Glacier Ear, Nose & Throat.

Referral For Audiological Evaluation

A form to be used by patients to secure a referral for a hearing test from their primary provider.

Authorization to release medical information from Glacier ent

Allows the patient to authorize the release of their medical information from Glacier Ear, Nose & Throat.

 
Credit Card Authorization Form

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.