Toll-Free 1-800-539-7208

Patient Forms
Your First Visit

For your first visit to Upper Cumberland Ear, Nose & Throat, you will need to bring the following information to facilitate your appointment:

Paperwork: We’ll ask you to complete a brief patient history questionnaire to help us to get to know you. We will use this information to help formulate a care program to address your condition or illness. Our staff will help assure that your insurance billing is as painless as possible. The paperwork we will need includes:

  • Patient’s Social Security Number
  • Insurance policy holder's Social Security Number
  • Insurance policy holder’s date of birth
  • Insurance card or copy of both the front and the back of the card
  • Insurance referral if required by your insurance company
  • List of medications the patient is presently taking

Time: During your first visit, you should plan on spending extra time in our office to discuss your medical history with our staff, as well as any recent health problems.

Consultation: You’ll meet a Board Certified specialist who will review your health history and discuss your concerns.

Examination: Your doctor will diagnose your condition, recommend diagnostic testing (if applicable), determine the exact cause or causes of your problem and discuss your treatment options.

Payment and Insurance

Payment is due at the time of service. We accept Visa, MasterCard and Discover as well as cash or money orders. We can help you determine if your service is covered by health insurance. Our physicians are on the panels of most health plans in this area. We accept assignment of benefits from Medicare.

Please bring your membership card for each plan you have.

If your plan requires a referral, it is your responsibility to obtain the referral prior to your visit. If your plan requires a copay, you will be expected to pay this at the time of service.

If your current insurance plan is not on our list, please call our office at 931-528-1575or toll-free at 800-539-7208 to discuss.

Medical Request Form

Please download a Medical Request Form from this page, then complete the form by typing into it or print it and complete it. Remember to bring this voluntary Authorization to Release Information form with you to your first or follow-up appointments.

Download Medical Release Form

What should I do? What should I expect?
Hearing Aid Buying Guide

Call today for a FREE hearing screening and consultation with one of our hearing professionals - 931.526.8863 or 800.526.5628.