First Name *

Last Name *

Child's First and Last Name (for pediatric patients)

Child's Date of Birth (if completing for a child)

Date of Birth

Phone *

Email *

Address *

City *

State *

Postal code *

Insurance *

Insurance

Anthem
Anthem Ky Medicaid
Anthem Medicare Replacement
Allsavers
Aetna
BCBS
CIGNA
Caresource Marketplace
Caresource Medicaid
First Health
GEHA
Humana
Humana Medicaid
Humana Medicare
Indiana Medicaid
Kentucky Medicaid
Passport
Passport Advantage
Tricare
United Healthcare
United Healthcare Medicare Replacement
United Healthcare Medicaid
Wellcare Medicare
Wellcare Medicaid
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Diagnosis *

Diagnosis

Ear Wax
Ringing In Ears (Tinnitus)
Dizziness/Vertigo
Ear Infection
Pain/Fullness in Ears
Ear Drainage
Hearing Loss
Evaluation for Tubes
TM Perforation
Meniere's
Sinusitis
Rhinitis
Polyps/Cysts/Masses (Inside Sinuses)
Nasal Allergies
Nasal Perforations
CSF Leak
Nosebleeds
Trouble with Smell or Taste
Deviated Septum
Tonsils/Adenoids
Tonsil Stones
Snoring
Sore Throat
Hoarseness
Trouble Swallowing
Cough
Thyroid Nodules/Goiters/ Other Thyroid Issues
Obstructive Sleep Apnea
Problem Not Listed
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Doctor *

Doctor

ANY DOCTOR
Elizabeth S. Burckardt, MD
Thomas S. Higgins, MD, MSPH
Sean M. Miller, MD
Bruce A. Scott, MD
Mark A. Severtson, MD
Sammy S. Sohi, MD
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Referring Provider

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