Our Patient Portal

Patient Forms

If you are a new patient, we will need you to complete paperwork before your initial visit. We have three convenient ways to complete the patient forms:


Option 1

Download, print, and complete the forms and bring them with you to your first appointment.

Option 2

Arrive at our office 15 minutes prior to your first appointment to complete the forms.

Option 3

Log-in to our secured patient portal, create an account, and complete the forms online.

We Accept Most Insurances

  • Blue Cross Blue Shield
  • Blue Cross Blue Shield Federal Emp Program
  • Health Net
  • Medicare
  • Humana
  • UHC Plans (Most)
  • UMR
  • TRICARE For Life
  • AARP
  • United Healthcare Plans (Most)
  • Railroad Medicare
  • Union Pacific RR EMP

Out-of-Network Insurances We Accept

  • Banner
  • Aetna
  • Meritain Health
  • Management Services
  • MVP Health Plan
  • AMS
At Windsor Audiology, we work for you, not your insurance company. Insurance is a great benefit, and we will do our best to make sure you receive the benefits under your insurance contract. Please know, we want the best outcome possible for you. The treatment we recommend, and our fees will always be based on your individualized needs and not your insurance coverage. If you have any questions, we will be happy to assist you.

No Surprise Act

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost

Good Faith Estimate

Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

  • You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services that are reasonably expected at the time of scheduling. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
  • For patients who don’t have insurance or who are not using insurance, make sure your provider provides a Good Faith Estimate of scheduled services in writing at least 1 business day before the medical service or item.
  • You can also ask any provider you choose, for a Good Faith Estimate before you schedule an item or service.
  • If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
  • Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, visit https://www.cms.gov/nosurprises or call 1-800-985-3059.

Your Rights and Protections Against Surprise Medical Bills

When you get emergency care or get treated by an out-of-network provider at an in- network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.

What is “balance billing” (sometimes called “surprise billing”)?

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a healthcare facility that is not in your health plan’s network.

“Out-of-network” describes providers and facilities that have not signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.

“Surprise billing” is an unexpected balance bill. This can happen when you cannot control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.

You are protected from balance billing for:

Emergency services

If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You cannot be balance billed for these emergency services. This includes services you may get after you are in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.

Certain services at an in-network hospital or ambulatory surgical center

When you get services from an in-network hospital or ambulatory surgical center, certain providers may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers cannot balance bill you and may not ask you to give up your protections against being balance billed.

If you get other services at these in-network facilities, out-of-network providers cannot balance bill you unless you give written consent and give up your protections.

You are never required to give up your protection from balance billing. You are also not required to get care out-of-network. You can choose a provider or facility in your plan’s network.

When balance billing isn’t allowed, you also have the following protections:

You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in- network). Your health plan will pay out-of-network providers and facilities directly.

Your health plan generally must:

  • Cover emergency services without requiring you to get approval for services in advance (prior authorization).
  • Cover emergency services provided by out-of-network providers.
  • Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits
  • Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.

If you think you have been wrongly billed, visit this website or call 1-800-985-3059 Visit www.cms.gov/nosurprises/consumers for more information about your rights under federal law.

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