Forms and Insurance

In order to provide the most efficient and comprehensive care to your child, please ensure the have the following items for all of your child's appointments:
• Your child’s health insurance card
• Any necessary referral/authorization number from your Primary Care Physician if required by your insurance plan (must be obtained prior to the visit)
• Co-payment (cash, check or Mastercard/Visa credit cards)
• All pertinent x-rays/scans,
• Results from any applicable diagnostic tests(hearing test, sleep studies, etc)
• Inform us of any changes in insurance, address, pediatrician
• NEW PATIENTS- must complete Intake Form below

Cancellations- please notify us as soon as possible if you need to cancel or change your scheduled appointment. A $50 No Show Charge will be applied to your account if you do not notify us of a cancellation (24 hours prior to appointment).

Patient Forms

• » Intake Form
• » Authorization for Medical Release

Insurance Information

Connecticut Pediatric Otolaryngology does participate with most insurance carriers in Connecticut, however please ensure we accept your insurance prior to your visit. We make every effort to coordinate payment for your visit with your insurance carrier. However, you must provide us with accurate, up to date information which will assist in the collection process. All claims that are denied by the insurance carrier are the responsibility of the patient and parent/guardian.