Release and Assignment — Plymouth ENT

Make an Appointment

New Patient Forms

Physicians

Dr. Bernard Durante

Testing and Instructions

Locations

Plymouth ENT at Bourne, MA

Plymouth ENT at Hyannis, MA

Plymouth ENT at Plymouth, MA

Plymouth ENT at Weymouth, MA

Specialties

Tinnitus Support

Head and Neck Cancer

Reflux, Voice and Swallowing

Procedures

Parotid Surgery

Laryngeal Surgery

Tonsil and Adenoid Surgery

Thyroid Surgery

Sinus Surgery and Balloon Sinuplasty - WBZ NEWS

In the Media

Sleep apnea by AMERICAN HEALTH FRONT, featuring Dr. Anit Patel.

Dr. Anit Patel talks about snoring and sleep apnea

Dr. Anit Patel speaking with Fox News on Driving impairment

A Conversation with Dr. Anit Patel

PCN Drs Orders - Allergies

South Shore Magazine

Make an Appointment

New Patient Forms

Physicians

Dr. Bernard Durante

Testing and Instructions

Locations

Plymouth ENT at Bourne, MA

Plymouth ENT at Hyannis, MA

Plymouth ENT at Plymouth, MA

Plymouth ENT at Weymouth, MA

Specialties

Tinnitus Support

Head and Neck Cancer

Reflux, Voice and Swallowing

Procedures

Parotid Surgery

Laryngeal Surgery

Tonsil and Adenoid Surgery

Thyroid Surgery

Sinus Surgery and Balloon Sinuplasty - WBZ NEWS

In the Media

Sleep apnea by AMERICAN HEALTH FRONT, featuring Dr. Anit Patel.

Dr. Anit Patel talks about snoring and sleep apnea

Dr. Anit Patel speaking with Fox News on Driving impairment

A Conversation with Dr. Anit Patel

PCN Drs Orders - Allergies

South Shore Magazine

Release and Assignment

Release And Assignment To My Insurance Carrier(s): This release and assignment form includes Medicare. I authorize the release of any medical information necessary to process this claim(s) and clarify that the above information is current and correct. I authorize payment of benefits to Plymouth ENT for services rendered. I understand and agree that (regardless of insurance status) I am ultimately responsible for the balance on my account for any professional services rendered. A photocopy of this form may be used in lieu of the original. Acknowledgement I hereby acknowledge I have read and/or received a copy of the Privacy Notice of Plymouth ENT *

Signature/ Date

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appointments@plymouthent.com

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30 Aldrin Road, Plymouth MA 508-746-8977

1 County Road, Bourne MA 508-746-8977

104 Park Street, Hyannis MA 508-746-8977

544 Main Street, Weymouth MA 508-746-8977