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Dear Patient and Family:
In keeping with its mission and core values, we are committed to providing health care for patients,
regardless of their ability to pay.
Our Financial Care:
Medical bills may be difficult to pay. Patients who are unable to pay for all or part of their health care
services, may apply for financial care by completing and returning this completed and signed form.
Patients and families who meet certain income requirements may qualify for free care based on their
family size and income, even if you have health insurance. To view our financial care policy and discount
guidelines visit St. Luke’s online https://www.stlukesonline.org
You must provide information on your family’s income. Income verification is required to
determine financial care. All family members 18 years old or older who are applying for
financial care must disclose every identified source of income.
Required documents for proof of income include the following:
• Most recent year’s income tax return, including schedules, if applicable
• Most recent pay stub(s)
• Most recent bank statement(s), to include all transactions (deposits & withdrawals) for all bank
accounts. If self-employed, provide 3 months for all business and personal accounts
• Documentation of any other source of income (proof of rental income, worker’s compensation
income statement, pension/dividends income statement, trust income statement, unemployment
benefit statement, etc.)
• Social Security award letter, if applicable
• If receiving public or other assistance, please provide documentation (food stamp verification,
cash assistance verification, etc.)
Alternative documents to those listed above:
• Written and signed statements from employers if unable to provide recent paystub
• Most recent"W-2" withholding statement if unable to provide recent year’s income tax return
If you have no proof of income or no income, please attach a letter of explanation.
Please send the application along with all required supporting documentation to:
Mail: St. Luke’s Health System
Attn: Financial Care
P.O. Box 2578
Boise, ID 83701
Fax: Attn: Financial Care
(208) 706-7619
If your application is incomplete, your information will be returned to you. Your account will be
placed on a 30 day hold awaiting the return of the completed application and additional required
document(s). Once a completed financial care application has been received St. Luke’s will send
written notification of the determination.
If you would like to discuss your financial situation, please contact a Customer Care Representative.
Call (208) 706-2333, toll free at 800-342-3432, or email pfscustomerservice@slhs.org.
Version 11/7/18
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Patient Name(s): Date of Birth:
Responsible Party Name: Marital Status:
Address: City:
State: Zip:
Social Security#: Date of Birth: Phone:
Employer: Phone: Hire Date:
Address: City:
Self Employed: Yes or No Occupation: State: Zip:
Spouse/Significant Other/Partner Name: Social Security#: Date of Birth:
Employer or Self Employed: Phone: Hire Date:
LIST MEMBERS IN HOUSEHOLD (use the back of this form for additional dependents names, DOB, and relationship) →
Dependents Name(s) Date of Birth Relationship
SOURCE OF INCOME RESPONSIBLE PARTY SPOUSE/SIGNIFICANT
OTHER/ PARTNER
Wages (before deductions) $ $
Child Support/Adult Support/Alimony $ $
Disability/Worker’s Compensation $ $
Pension $ $
Social Security Income $ $
Dividends/interest/ Trust/Estate/ Rental Income $ $
Public Assistance/Food Stamps/Unemployment etc. $ $
Income from other sources (please specify) $ $.
Total $ $
How much are you able to pay St. Luke’s Health System monthly?
Version 11/7/18
By signing and submitting this application to St. Luke’s, I certify that all of the information I provided is true and complete to the best of my knowledge. If I
knowingly and with intent to defraud or deceive, provide false information, I will be denied financial assistance e for current and future services, and will be
liable for any and all charges.
I authorize St. Luke’s Health System to verify the information I have provided.
Responsible Party Signature Date
For PFS Use Only: Epic Guarantor Number(s):
If expenses are more than the income listed, please use the back of this form to describe how expenses are met each month. →
Request for Financial Care Application
(Behavioral Health/Primary Care Shortage Areas)
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National Health Services Corp Locations
*Please note: This application will only be used to review patient balances at the following St. Luke’s locations:
St. Luke’s Clinic – Internal Medicine
625 Pole Line Road W Suite 1A/2A Twin Falls, ID 83301
St. Luke’s Clinic – Psychiatric Wellness Services
703 S. Americana, Ste 150 Boise, ID 83702
St. Luke’s Clinic – Behavioral Health Services
414 Shoup Ave W Suite B Twin Falls, ID 83301
St. Luke's Children's Center for Neurobehavioral Medicine
1075 E. Park Blvd., Boise ID 83712
St. Luke's Clinic – Physician Center
775 Pole Line Road W Suite 105/111. Twin Falls, ID
St. Luke’s Clinic – Psychiatric Wellness Services
9850 W. St Luke’s Drive, Ste 329 Nampa, ID 83687
St. Luke's Clinic – Physician Center
2550 Addison Ave E Suite A,B, F. Twin Falls, ID
St. Luke’s McCall Medical Center (hospital only)
1000 State St. McCall, ID 83638
St. Luke’s Clinic Physician Center
529 Broadway Ave. S Buhl, ID 83316
St. Luke’s Clinic- Payette Lakes Family Medicine
211 Forest St. McCall, ID 83638
St. Luke’s Clinic - Jerome Family Medicine
132 5th Ave. W Suites 1 & 2 Jerome, ID 83338
St. Luke’s Clinic- Behavioral Health Services
301 Deinhard Lane McCall, ID 83638
St. Luke’s Clinic – Mental Health Services
1450 Aviation Dr Suite 202 Hailey, ID 83333
St. Luke’s Clinic- Family Medicine
1210 NW. 16th St. Fruitland, ID 83619
St. Luke’s Elmore Medical Center
895 N. 6th E. St. Mountain Home, ID 83647
St. Luke’s Clinic- Trinity Mountain Medical
465 McKenna Dr. Mountain Home, ID 83647
St. Luke’s Clinic Eastern Oregon Medical Associates
3950 17th St. Baker City, OR 97814
Version 11/7/18

Dear Patient and Family Members:
Welcome to Florida E.N.T. and Allergy, a Division of Select Physicians Alliance. We would like to take this
opportunity to welcome you to our practice. This letter contains answers to some of the most commonly asked
questions by patients entering our practice. We hope you find this information useful.
Our office hours are Monday through Friday from 8:30 am to 5:15 pm. Our office telephone number is (813)-
879-8045. In the event of an emergency outside of our normal business hours, please contact the office and the
call service will contact the doctor on call for you.
We understand that in today’s busy world occasionally situations come up that are beyond your control. In those
instances, we request you extend us the courtesy of a 24-hour notice. This courtesy allows us to continue to
operate efficiently and use the time that was reserved for you to help other patients in need. It is our policy that
you call our office at least 24-hour prior to your appointment time. If you fail to contact our office in advance
three times over the course of one year, you will be discharged from the practice.
Patients should complete, sign and bring the following items to your first appointment:
o Plan to arrive 20 minutes prior to your appointment time to finalize paperwork.
o Bring healthcare insurance ID cards and picture ID.
o Bring authorizations or referrals as required by your insurance carrier.
o Complete and sign the Patient information, Notice of Privacy Practices. Medical History/Medication
List, Policies and Guidelines, Prescription Consent Form.
o Complete the name, phone number, and address of your preferred pharmacy on form.
o Have your referring physician office fax pertinent medical records, diagnostic and lab testing, and bring
them with you.
o Bring a CD or Film of your most recent MRI and/or CT if applicable.
On subsequent visits our front office staff will review your demographic and insurance information with you to
ensure we maintain your correct information on file. This allows us to submit claims to your insurance carrier in
a timely manner.
We are contracted with several insurance carriers for the benefit of our patients. You will want to check your
benefits booklet or with the benefits department of your employer to verify if our physicians are listed as
providers within your network.
As part of our contract with the insurance companies we are legally required to collect any co-pays or
deductibles from you at the time of service. We ask that you be prepared to pay your copay at the time of checkin
prior to being seen by our providers. We accept cash, check, American Express, Discover, MasterCard, Visa,
and CareCredit.
Brandon Office
1139 Nikki View Dr
Brandon, FL 33511
Lutz Office
4211 Van Dyke Road
Lutz, FL 33558
North Tampa Office
3000 Medical Park Drive,
Suite 200, Tampa, FL 33613
Plant City Office
511 W. Alexander St. Suite 1
Plant City, FL 33563
Riverview Office
13015 Summerfield Square Dr
Riverview, FL 33578
Tampa Office
5105 N Armenia Ave
Tampa Bay, FL 33603
Wesley Chapel Office
26853 Foggy Creek Road
Building 21, Suite 101
Wesley Chapel, FL 33544
Westchase Office
7433 Monika Manor Drive
Tampa, FL 33625
Name: ___________________________________________ Date of birth: ________________
Office Guidelines
Thank you for choosing our doctors for your ENT care. While it is our desire to provide you with the best care
possible, there are some limitations and restrictions that your managed care or insurance plan may impose
which we cannot control. Because of this, there are certain polices and guidelines that we want you to be aware
of and agree when dealing with our office as outlined below:
1. Payment is due at time of service.
2. Cancellation Policy: We require that you give our office at least 24-hour notice if you need to cancel or
reschedule an appointment. For office visits you will be subject to a $50.00 charge, and for all in office
procedures, such as, videonystagmography (VNG), allergy testing, CT scans, and speech evaluations
you will be subject to a $100.00 charge. All surgery cancellations also require at least 72-hour notice or
you will be subject to a $100.00 charge.
3. Obtain authorization (if necessary) prior to your visit to avoid delays or rescheduling.
4. We expect that any lab test, x-rays, surgery, or other diagnostic exams that we order will be done within
7-10 days. We are not party to or agree with your insurer or managed care plan if they deny
authorization or coverage. If your plan denies authorization for our recommendations we ask that you
initiate an appeal with them immediately and notify us in writing. If they require a letter from us, we
will provide it.
5. Make a follow-up appointment within one week after you have done any diagnostic test (i.e. lab, xray,
CT scans, biopsies, etc.) to discuss the results and recommendations. Do not wait for us to call
you.
6. You are responsible to contact the physician or his staff for an appointment if your condition does not
improve within two weeks.
7. Your condition may require further procedures and examinations as part of the workup for your medical
problem; however, most insurance carries require prior approval. You will be financially responsible for
all fees that your healthcare insurance deems as non-covered services or not medically necessary and
services must be paid at time of service.
8. Self-pay patients initial payment is for consultation only. You will be responsible for in-office
procedures. The patient, child’s parents, or responsible person will be made aware of any additional outof-pocket
expenses prior to the provider performing the procedure and services must be paid at time of
service.
9. Managed care, with its multiplicity of rules that govern the practice of medicine, make it difficult for
even us to be sure they are being followed. It is not our intention to bill contrary to your plan. If you
discover any errors in billings (surgical, laboratory, x-ray, or even ours) please inform us so that we can
correct or help you to correct them.
10. There will be a charge for any and all medical leave papers (FMLA) filled out by this office. As a
courtesy, a one page diagnostic report will be furnished upon request.
11. You can expect to be treated with respect and professionalism at all times. If you have a problem with
any of our staff, please notify the doctor or the office manager.
Signature _________________________________________________ Date _______________
(Patient, Parent or Guarantor)
Assignment of Insurance Benefits
The undersigned hereby authorizes the release of any information relating to all claims for benefits submitted on
behalf of myself and/or dependents. I further expressly agree and acknowledge that my signature on this
document authorizes my physician to submit claims for benefits, for services rendered or for services to be
rendered, without obtaining my signature on each and every claim to be submitted for myself and/or
dependents, and that I will be bound by this signature as though the undersigned. I further authorize my
insurance company to pay and hereby assign directly to Florida ENT and Allergy all benefits, if any, otherwise
payable to me for services as described on attached forms. I understand that I am financially responsible for all
charges incurred. I further acknowledge that any insurance benefits, when received by and paid to Florida
E.N.T. and Allergy, will be credited to my account in accordance with the above said assignment.
Financial Agreement
In consideration of the services rendered to the patient, the undersigned agrees to accept full financial
responsibility for the patient’s account in accordance with the regular rates and terms of the facility. Should the
account be referred for collection procedures, the undersigned shall pay responsible attorney’s fees and
collection expenses. At present, that fee is a minimum of 30% of charges collected and is payable before the
patient is seen in the office of Florida E.N.T. and Allergy at next visit.
Signature _________________________________________________ Date _______________
(Patient, Parent or Guarantor)
Notice of Privacy Practices Acknowledgement
By law, we are required to make available to you a copy of our Notice of Privacy Practices (“Notice”). By
signing below you acknowledge that you received, or been offered and declined, a copy of the Notice.
A current copy of this Notice is also posted in the office, or is available to you upon request. If the Notice is
revised, you may review and obtain the new version at any time.
You may decline to sign this acknowledgement.
I have received, or declined, a copy of the Notice of Privacy Practices
Patient Name (print) _________________________________________________________________
Signature of Patient (or Legal Representative) _____________________________________________
*If Legal Representative, list relationship to patient _________________________________________
Date _____________________________________
For office use only:
We were unable to obtain this written acknowledgement of Notice of Privacy Practices because: __________
______________________________________________________________ . Staff Initials ______________
Authorization for Release of Information
As part of your healthcare, this practice originates and maintains paper and/or electronic records describing your
health history, symptoms, examinations, test results, diagnoses, and treatment, any plans for future care or
treatment and payment for the services or treatment we provide. We use this information to:
��� Plan your care and treatment.
��� Communicate with other health professionals or entities who contribute to your healthcare.
��� Submit you diagnosis and treatment information for payment for the services or treatment provided to
you.
To leave appointment reminders or other minimum necessary information related to your healthcare or
healthcare payments on your answering machine, your mobile voice mail or with a household family member.
[ ] Please check here if you do not want us to leave message on your answering machine or with a
household family member.
[ ] Please check here if you do not want us to leave a message on your mobile voice mail.
Permission to Treat
I, ______________________________, authorize Florida E.N.T. & Allergy and its personnel to provide medical services
(Print name of patient/legal guardian)
services such as medical examination and treatment, as they deem best for the patient’s physical or mental welfare.
_____________________________________ _______________________ ___________________________
(Print Patient’s Name) (Date of Birth) (Social Security Number)

I authorize the following person/people to discuss any necessary treatments, medications and to authorize any tests and/or
labs that are necessary up to and including admission to the hospital. I authorize the following person/people to bring my
child in for treatment and to discuss any necessary treatments, medications and to authorize any tests and/or labs that are
necessary up to and including admission to the hospital.
Name: __________________________________________________ Relationship to Patient: __________________
Name: __________________________________________________ Relationship to Patient: __________________
Name: __________________________________________________ Relationship to Patient: __________________
Name: __________________________________________________ Relationship to Patient: __________________
** All of the above listed will provide identification to be placed in the patient’s chart**
I agree that unless I give specific instructions otherwise, medical information regarding my treatment or my child’s
treatment may be released to the biological parents, step parents, referring physicians and other practitioners, and
my insurance company.
Signature _________________________________________________ Date _______________
(Patient, Parent or Guarantor)
STANDING CONSENT TO ACCESS EXTERNAL PRESCRIPTION HISTORY
Please sign only after you have read and understand the following
I, ____________________________, whose signature appears below, authorize Florida E.N.T.
(Print name of patient/legal guardian)
and Allergy, a Division of Select Physicians Alliance, PL and its affiliated providers to view
external prescription history via the RxHub service for the patient listed below.
Please initial below an option below. By initialing, you are agreeing to the respective terms and
conditions set below and are fully agreeing to the terms above.
________ I understand that prescript history from multiple other unaffiliated medical providers,
insurance companies, and pharmacy benefits managers may be viewable by my providers and
staff here, and it may include prescripts issued back in time for several years.
________ I understand yet wish to revoke authorization.
My signature certifies that I have read and understand that information above and that I
authorize the access to my prescription history.
Patient Name (print) _________________________________________________________________
Signature of Patient (or Legal Representative) _____________________________________________
*If Legal Representative, list relationship to patient _________________________________________
Patient Information Date of Service ____/____/____
Last Name _________________________________ First Name ____________________________ MI ______
Date of Birth ____/____/____ Sex _________ Social Security Number _________________
Address __________________________________City _____________________ State ________ Zip _______
Home Phone ( ) _______________Cell Phone ( ) _______________ Work Phone ( ) _______________
Email Address _____________________________________ Marital Status (circle) S M D W P SEP
Preferred Language _______________________________ Ethnicity: Asian Asian Indian African American White
Employment Status (circle) Employed Retired Student Other ___________ Race: ___________
Referring Physician ____________________________ Primary Care Physician _________________________
Pharmacy ____________________________________ Pharmacy Phone ( ) ___________________________
Emergency Contact ____________________________ Relationship to Patient __________________________
Emergency Contact Phone ( ) ___________________
Responsible Party (Is the Patient the financially responsible party? If NO, please complete this section)
Last Name _________________________________ First Name ____________________________ MI ______
Date of Birth ____/____/____ Sex _________ Social Security Number _________________
Address __________________________________City _____________________ State ________ Zip _______
Home Phone ( ) _______________Cell Phone ( ) _______________ Work Phone ( ) _______________
Email Address ___________________________________ Relationship to Patient ______________________
Insurance Information
PRIMARY Insurance Plan Name _____________________________ Insurance ID # ____________________
Insurance/Card Holder’s Name _________________________________ Relationship ____________________
Insured’s Date of Birth ____/____/____ Insured’s Social Security # ____________________
Insurance Plan Phone ( ) __________________ Insurance Plan Address ______________________________
SECONDARY Insurance Plan Name _____________________________ Insurance ID # _________________
Insurance/Card Holder’s Name _________________________________ Relationship ____________________
Insured’s Date of Birth ____/____/____ Insured’s Social Security # ____________________
Insurance Plan Phone ( ) __________________ Insurance Plan Address ______________________________
Patient Name: DOB: Height: Weight:
Drug Allergies: Other Allergies:
Reason For Appointment:
Pharmacy: Location: Phone#:
SURGICAL /HOSPITALIZATION HISTORY See Attached List
Operation(s) Year Hospitalization(s) Year
MEDICATION LIST See Attached List
Please list ALL medications (include over the counter drugs) you are taking now, include dosage & frequency
Medication Dosage Frequency Medication Dosage Frequency
Alcohol Consumption: Never Rare Occasionally Socially N/A How Many Per Day?
Smoking History Never Former Current Smoking Type: Cigarettes Cigar Pipe Chew
How many packs a day? When did you quit? How many years did you smoke?
Has the patient been exposed to second hand smoke? Yes No
MEDICAL HISTORY Please indicate if you have/had a history of the following:
Thyroid Disease High Blood Pressure Tuberculosis Malignant Hyperthermia
Headaches High Cholesterol HIV Blood/Bleeding Disorder
Asthma Heart Disease Mental Illness Gastrointestinal/Stomach Problems
Lung Disease Kidney Disease Depression Hepatitis/Liver Disease
Emphysema /COPD Diabetes Stroke/CVA/TIA Could you be pregnant?
Rheumatic Heart Disease Cancer Arthritis Other: ________________________
FAMILY HISTORY: Do any blood relatives have any of the following? State which relative.
Diabetes Heart Disease/Attack Stroke Thyroid/Cancer High Blood Pressure Bleeding Disorders
REVIEW OF SYSTEMS Please indicate if you are currently having problems with any of the following:
Constitutional Visual Disturbance Hearing Loss Gastroenterology Respiratory
Fever Dry Eyes Cardiology Loss of Appetite Asthma
Recent Weight Gain Double Vision Chest pain Nausea or Vomiting Shortness of Breath
Recent Weight Loss ENT Irregular Heart Rhythm Heartburn Cough
Night Sweats/Chills Nosebleeds Murmur Change in Bowels Spitting up Blood
Fatigue Hoarseness Endocrinology Difficulty Swallowing Neurology
Skin Ringing in Ears Leg Swelling Hematology Headaches
Skin Cancer Allergies Sleep Problems Easy Bruising Stroke
Healing Problems Runny Nose Temperature Intolerance Bleeding Disorder Paralysis/Weakness
Rash Sneezing Excessive Thirst Anemia Tingling/Numbness
Discoloration Snoring Blood Clots in Legs Seizures
Eyes Throat Pain Dizziness
Glaucoma Ear Drainage Memory Loss
I certify that I have disclosed all of my medical history known to me. I acknowledge that I am responsible to make your office
aware of any changes to my medical health. Patient Signature: ___________________________ Date: _________________
WELCOME and THANK YOU for choosing Florida E.N.T. and Allergy for your healthcare
needs.
We have exciting news regarding your health care!!
As we continue in our efforts to provide you, our patients, with the highest quality of care and
convenient access to your health records, we are excited to announce that our practice now
offers a “Patient Portal”. This will allow you the opportunity to use the power of the web to
track all aspects of your health care through our office.
As part of the Affordable Care Act implemented by the Federal Government, we are required
by law to provide our patients access to communicate with our practice easily, safely, and
securely over the internet by means of a “Patient Portal”.
During your visit, our office will provide you with your personal “Login Credentials” which
consists of the Login URL, your user ID and your password. Our staff is dedicated to ensuring
that you are knowledgeable regarding the portal features and that you have access prior to
leaving.
However, TIME is of utmost importance for our office!
If for any reason, you are not able or do not want to access the portal while at our office, please
take a few minutes to login once you get home.
Due to governmental regulations and guidelines regarding Meaningful Use, our patients are
required to login within 4 days of their office visit. However, although you have access to your
medical records, please be mindful that our physicians will need adequate time to complete your
visit summary prior to availability on the portal.
Should you encounter an issue in completing this process, please allow one of our qualified
staff to assist you by calling the office (813) 879-8045.
Once again, we welcome you to our Florida E.N.T. and Allergy healthcare family!
Kind Regards,
The Physicians and staff of
Florida E.N.T. and Allergy

posted by Isaac Hobart at 10:03 AM