Boris Karanfilov, M.D. 

Sumit Bapna, M.D. 

5378 Avery Road 

Dublin, Ohio 43016 

 
Managed Care Insurance 

Ohio Sinus Institute will submit insurance claims for medical/surgical services provided to patients with 
insurance coverage in a managed care plan (PPO, HMO, POS) that our office participates in. A copy of 
your insurance card must be presented to our office. Patients without an insurance card must pay at the 
time of service. Patients presenting valid cards with PPO, HMO and POS identification are required to 
pay their co-pay amount, if applicable, at the time of service. Managed care discounts will not be 
honored if the insurance card provided at the time of service does not indicate a plan that our office 
participates in. For patients in participating plans, charges for services rendered will be sent to your 
insurance company for direct reimbursement to our office. You will receive a statement if a balance 
representing your portion owed remains due after we receive payment from your insurance company. If 
you participate in an HMO or POS plan that requires authorization from your primary care physician, 
we require a referral or authorization number at the time of service in order to submit your insurance 
claim for payment. Without a referral or authorization from your primary care physician, your benefits 
may be reduced or denied entirely. HMO patients without referrals incurring medical services or 
seeking out-of-network services will be required to pay at the time of service.  

 
Medicare and Medicaid Insurance 

Ohio Sinus Institute accepts Medicare and Medicaid assignment. Copies of current Medicare and 
Medicaid cards are required. Medicaid cards with invalid dates will not be accepted and patient will be 
required to pay at the time of service. Our office will submit claims to Medicare, the Illinois 
Department of Public Aid and participating Medicare supplemental plans for reimbursement. Insurance 
payment will be issued to Ohio Sinus Institute. If a balance representing your co-insurance, deductible, 
or non-covered portion remains due after insurance payment is received, you will receive a statement 
indicating your portion owed. A 15% discount will be honored for non-covered services that are paid in 
full at the time of service. 
 

Traditional Indemnity Insurance 

For Patients with traditional indemnity coverage, our office will submit a claim to your insurance 
company for direct reimbursement to Ohio Sinus Institute. If a balance remains due after insurance 
payment is received, you will receive a statement indicating your portion owed. 
  

Self-Pay 

Patients without medical insurance are requested to pay at the time of service. If you cannot pay for 
medical services in full, you may consult with a member of our business office staff to arrange a 
payment plan. Payment plans remain an option for all patients regardless of insurance coverage. I 
understand the provisions of Ohio Sinus Institute’s Billing Policy as they apply to me. I further 
understand that I am financially responsible for any charges not covered by my insurance plan and that 
full payment is due within 90 days of the date of the service(s). I understand that if my balance exceeds 
90 days, credit and collection procedures will commence and a monthly interest charge at the rate of 1% 
of the outstanding balance will accrue on my account unless special financial arrangements are made in 
advance with the office staff. 

 
 

___________________________________________________________________________________ 
Date 

 

 

Patient Name   

 

Signature of Patient/Responsible Party 

 

 

 

 

 

 

 

Assignment of Benefits and Records Release Form 

 

Release of Records: 

 

 

I hereby authorize Ohio Sinus Institute to provide diagnostic and treatment services to me.  Ohio Sinus 
Institute has my permission to release any information needed for completion of their claims for 
payment from third party payers, including but not limited to: insurance companies, health maintenance 
organizations government agencies and their representatives.  I permit release of information 
concerning dates of treatment, condition, diagnosis, procedures or surgeries to my personal physician, 
referring physician, and/or the referring facility or for follow-up care.  I am aware that this authorization 
to release information may include information regarding HIV or AIDS, alcohol or drug abuse, and/or 
psychiatric treatment. 
 
 
___________________________________________________________________________________ 
Date 

 

 

Patient Name   

 

Signature of Patient/Responsible Party 

 

 

 

 

 

Assignments of Benefits:

 

 
I acknowledge financial responsibility for all facility and physician(s) fees.  I understand that the 
physician billing office will file my insurance claim if my physician/provider is a participating provider 
with my insurance carrier and I assign direct payment to the physician all payments made under the 
terms and provisions of my policy.  I further understand that any disputes on coverage are between my 
insurance carrier and myself and I will be responsible for payment for denied services regardless of the 
outcome of my dispute.  I understand that I am responsible for and will pay my portion of the unpaid 
balance due for services performed by the facility and physician/provider. 
 
 
___________________________________________________________________________________ 
Date 

 

 

Patient Name   

 

Signature of Patient/Responsible Party 

 

 

 

 

 

 

*********************************************************************************** 

Authorization for Medicare Patients Only 

 
I request that payment of authorized Medicare Benefits be made either to me or on my behalf to Ohio 
Sinus Institute for any services unfurnished to me by that physician.  I authorize release to the Health 
Care Financing Administration and its agents any medical information about me to determine the 
payments for related services.   
 
In Medicare assigned cases the physician agrees to accept the charge determination of the Medicare 
carrier as the full charge.  I am responsible only for the deductible, coinsurance, and noncovered 
services.  Coinsurance and deductibles are based upon charge determination of the Medicare carrier. 
 
I understand that my signature requests that payment be made and authorizes release of medical 
information necessary to pay the claim.  If item 9 on HCFA-1500 claim form is completed, my 
signature authorizes release of the information to the insurer of agency shown. 
 
This authorization is in effect for my lifetime or until I choose to revoke it. 
 
___________________________________________________________________________________ 
Date    

 

Signature of Medicare Beneficiary 

 

 

 

 

     

 

 

Acknowledgement of Receipt of Privacy

 

 

Your privacy is important to us.  We create information about you so we may provide you with quality 
care.  We are committed to protecting this information.  The Notice of Privacy Practices describes your 
rights with regard to your health information.  This is a summary of the more detailed information 
contained in out Notice of Privacy Practices. 
 
Your rights include: 
 

- A right to inspect and copy your medical information 

 

- A right to amend your health information 
- A right to request restrictions on what information we use or how we disclose your health 
information 
- A right to receive an accounting of certain disclosures we have made of your health 
information 

 

- A right to receive a paper copy of our Notice of Privacy Practices 

 
These rights do have special restrictions, so it is important that you read the full Notice. 
 
We may use your health information and/or records to: 

- Plan for your care 

 

- Help your health care providers communicate and work together to care for you 

 

- Submit bills to pay for your care 

 

- Help health care payers make sure services were actually provided 

- Help improve the quality of health care.  For example, after your visit we may contact you to 

see how you are doing and find out how you felt about our service 

- Disclose information to certain officials or organizations where we may, or are required to do 

so by law 

 
I have received or I have been provided the opportunity to receive a copy of the “Notice of Privacy 
Practices” that explains when, and why my confidential health information may be used or shared.  I 
acknowledge that Ohio Sinus Institute physicians and other Ohio Sinus Institute staff may use and share 
my confidential health information with others in order to arrange for payment of my bill and for issues 
that concern Ohio Sinus Institute operations and responsibilities.   
 
 
___________________________________________________________________________________ 
Date 

 

 

Patient Name   

 

Signature of Patient/Responsible Party   

 
 

 

 

 

 

Signature of staff member delivering notice: _______________________________________________ 
 
*********************************************************************************** 
Attempt to Deliver Notice of Privacy Practices: 
 
___________________________________________________________________________________ 
Patient Name   

 

 

 

 

 

 

 

 

Date 

 
However, delivery could not be made because: 
___________________________________________________________________________________ 
 
___________________________________________________________________________________ 
Signature of Practice Employee   

 

Title 

 

 

 

   

Date