Loudoun ENT Specialists
Betsy Vasquez, MD, FACS
New Patients Are ALWAYS Welcome
(click to download forms)
PLEASE BRING ANY AND ALL LABS, XRAYS, CT/MRI FILMS, with the accompanying REPORTS pertaining to your problem, etc to your appointment.
THIS IS VERY IMPORTANT INFORMATION NEEDED BY OUR PRACTITIONERS.
Your appointment will be delayed without this information.
If you are a new patient to our practice
We offer the best of ENT in Sterling and Loudoun County. Our practice request the registration forms be completed and brought to your first appointment. By completing the forms prior to your visit, you will experience quicker check-in time. When visiting our office, please be prepared to pay your copay, coinsurance or deductible.
Federal Red Flag Regulations require our office to request a copy of a picture ID and insurance card to confirm identity. Please bring these items with you to your appointment.
Please complete ALL 4 pages of our registration form. If you experience any difficulties downloading our forms, please call our office for assistance.
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Loudoun ENT Specialists Credit Card on File Policy (2014)
Loudoun ENT Specialists requires that a valid credit card be kept on file.
This policy is designed to:
The card information is stored electronically in an encrypted form and cannot be viewed by our office staff. Your signature will authorize the card to be used only when your balance becomes past due.
How the policy works:
1. At the time of registration or check-in, you will be asked for your credit card information to be electronically stored in encrypted form in our computer. Only the last four digits are visible to our staff.
2. As before, we will bill your insurance carrier as a courtesy for all charges related to the visit.
3. When we receive an explanation of benefits (EOB) from your insurance, we will send you a statement. If we have not received payment within 30 days, we will charge the credit card on file for the balance due (on statement).
4. If Loudoun ENT Specialists attempts to use your card and it is declined or has expired, Loudoun ENT Specialists will send you a new statement with a note attached asking for current credit card information.
Please remember that this policy does not restrict your right to appeal any charge made to your credit card. Should you feel that we have charged your card in error, you may contact our billing office. If a mistake has been made we will reverse the charges.
Established Patients - We are happy you have come back to see us.
In most cases a patient will need to update their chart by completing one or all of the registration forms once a year.
If you have had an address, insurance or a name change since you last saw our doctors, please print and complete page 1 of the patient registration forms.
Patients who have not been in our office in the past year may be required to complete all forms, as our office policies may have changed since the last visit.