Potomac ENT - The ENT Doctors of Lake Ridge Virginia

Patient Resources

About Your Visit

Thank you for choosing us as your ENT provider. We are committed to providing you with quality and affordable health care! In order to process your visit more efficiently and get you into your appointment more quickly, please arrive 30 minutes prior to their scheduled appointment time if you have not filled out your medical history forms ahead of time. If you have downloaded and reviewed the forms ahead of time, please arrive 15 minutes prior to your scheduled appointment time. The complete Registration Packet can be found below under "Patient Forms".

Patient Forms

Complete Registration Packet

Medical Records REQUEST Form

Medical Records RELEASE Form

Office & Payment Policies

Thank you for choosing us as your ENT provider. We are committed to providing you with quality and affordable health care. In an effort to answer all of your billing and insurance payment questions we have developed this payment policy. Please read it, ask us any questions you may have, and sign in the space provided. A copy will be provided to you upon request.


We participate with most insurance plans, including Medicare and Medicaid. Knowing your insurance benefits and providing us with an up-to-date insurance card and a referral if required is your responsibility. Please contact your insurance company if you have any questions regarding coverage. If you are not insured by an insurance plan we do offer a self-pay option, payment in full is expected at each visit. If you are insured by a plan but do not have an up-to-date insurance card with you payment in full at each visit is required until we can verify your coverage.

Co-Payments and Deductibles

All co-payments and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company. Failure on our part to collect co-payments and deductibles from patients can be considered fraud. Please help us in upholding the law by paying your copayment at each visit.

Non-Covered services

Please be aware that some – and perhaps all – of the services you receive may be noncovered or not considered reasonable or medically necessary by Medicare/Medicaid or other insurers. Noncovered services are required to be paid in full at the time of service.

Proof of Insurance

All patients must complete our patient information form before seeing the doctor. We must obtain a copy of your driver’s license and current valid insurance card to provide proof of insurance. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the balance of a claim.

Claims submission

We will submit your claims and assist you in any way we reasonable can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company; we are not a party to that contract.

Coverage changes

If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits. If your insurance company does not pay your claim in 90 days, the balance will automatically be billed to you.


If your account is over 90 days past due, you will receive a letter stating that you have 10 days to pay your account in full. Partial payments will not be accepted unless otherwise negotiated. Please be aware that if a balance remains unpaid, we may refer your account to a collection agency and you may be discharged from this practice. If this is to occur, you will be notified by regular and certified mail that you have 30 days to find alternative medical care. During that 30-day period, our physician will only be able to treat you on an emergency basis.

Missed Appointments

Our policy is to charge $50.00 for missed appointments (excluding surgery and VNG) canceled less than 24 hours in advance. Surgery and VNG appointments must be canceled 1 week in advance otherwise there will be a charge of $150.00. These charges will be your responsibility and billed directly to you. Please help us to serve you better by keeping your regularly schedule appointment.

Returned Check Fee

There is a $35.00 fee for checks that are returned due to insufficient funds.
Our practice is committed to providing you with quality patient care. Our prices are representative of the usual and customary charges for our area. Thank you for understanding our payment policy. Please let us know if you have any questions or concerns.

Accepted Insurance Providers


Aetna - No Aetna better health

Anthem BCBS

Anthen Healthkeepers Plus


BC/BS Federal Employee Program

Carefirst BC/B

Cigna - No Cigna Connect

Core Source

Coventry Health Services

Empire BC/BS

Golden Rule

Highmark Medicare Services

Horizon Blue Cross of NJ


Medicaid Virginia

Medicare Virginia

Onenet PPO



Railroad Medicare



United Health Care - No UHC Community Plan / No Compass

United Healthcare Government Employee Health Association

VA Premier


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