FORMS

NEW PATIENT INTAKE FORM

Please fill this out before you call to schedule your first appointment with us

COVID-19 TESTING FIRST-TIME TESTING FORM

This is the form to complete before scheduling COVID testing the first time with us

COVID-19 TESTING REPEAT-VISIT FORM

This is the form to complete before scheduling repeat COVID testing with us

EAR PIERCING INTAKE AND CONSENT FORM

This should be completed before scheduling ear piercing with us

AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION

This is a form to allow us to obtain your health records from elsewhere or to send them elsewhere

FINANCIAL AGREEMENT

This form acknowledges our financial policies

NOTICE OF PRIVACY PRACTICES

This is our Notice of Privacy Practices that discusses how medical information may be used and how you can gain access to this information.

PREAUTHORIZATION TO TREAT MINORS CONSENT FORM

This form allows a parent or legal guardian of a minor child to grant permission to another adult to bring their child to our clinic for medical care

TELEHEALTH CONSENT

This form grants permission to be provided medical care by telephone or videocall

IN NETWORK

We are on more and more plans all the time!

IN PROCESS

Plans for which approval is pending (considered out of network)

OUT OF NETWORK

More affordable than you might think

TELEMEDICINE

Riviera ENT is dedicated to providing ENT care even in times of crisis. Thanks to modern technology, we will still be able to provide new and existing patients with a direct avenue of communication to their ENT physicians. While this is an excellent surrogate option for some of our patients, our office is still open for urgent ENT issues.

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CONSENT FOR TELEMEDICINE​

• We request your consent for telehealth by asking you to complete this online form found HERE. 

• If you would like a copy of Riviera ENT's telehealth consent, you may find it HERE or request that we email this to you.

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TIPS FOR A SUCCESSFUL TELEMEDICINE VISIT

• Check your internet connection

• Make sure your audio and video are working and enabled

• Please check in at least 20 - 30 minutes before your visit using your cell phone, tablet, laptop or desktop

• Find a quiet, private location if possible

• Check your lighting

• Write down problems and questions ahead of time

• Dress appropriately for the visit

• Consider using headphones

• Be an active participant in the exam

• Have a trusted assistant if necessary

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PATIENT PORTAL

October 2020 Update: We have switched to a new medical record system, Elation, to better serve you.  We anticipate access to a patient passport in the near future.  We also changed our billing company to provide you better service.

To schedule an appointment:

• please call 805-327-6673, or

• email us at info@rivieraent.com

WHAT TO BRING TO YOUR APPOINTMENT

For new patients, completing our online portal is the best way to prepare for your visit. Your health information is secure and protected through the portal and will save you time on your first visit.

To help us give you the best possible appointment experience, please bring with you:  

• A photo ID and health insurance card

• If you have not completed the portal:

  • A list of all your medications and allergies 

  • Your medical history

  • Your preferred pharmacy

  • PLEASE ARRIVE 15-20 MINUTES EARLY TO COMPLETE PAPERWORK

• Pertinent Outside Medical Records

  • Please complete the MEDICAL RECORD RELEASE FORM ahead of your visit 

  • Copies of outside imaging studies, including the actual images themselves if possible

• If your child will be coming with a non-parent or non-legal guardian, you will need to have completed the PREAUTHORIZATION TO TREAT MINORS CONSENT FORM before the visit

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We thank you for your diligence and look forward to seeing you at your appointment!