Financial Policy Acknowledgment Posted on June 9, 2026 by PDX ENT Financial Policy Acknowledgment First Name(Required) Last Name(Required) Email(Required) All co-payments are due at the time of service as stated in your insurance contract. If self-pay, payment is due at time of service. If payment plans are needed, please consult the billing department.(Required) If your insurance carrier requires a referral you will need to have that in place before your appointment. If a referral is needed and not obtained prior to the appointment, your appointment may be cancelled.(Required) I hereby authorize payment of medical benefits to PDX ENT Audiology Medical Group. I authorize the release of any medical information necessary to process a claim. I acknowledge that I am financially responsible for all charges not covered by commercial or Medicare insurance.(Required) No-show and late arrival policy: We request that you give our office a 24-hour prior notice in the event that you need to reschedule or cancel your appointment. If you do not contact us, we will consider this a no-show. Any late arrivals will need to be rescheduled. All no-show events will be assessed with a $100 fee that will be billed to you directly and is not covered by your insurance.(Required) By signing, I agree and understand all of the above: Signature(Required) Date(Required)
