Online Forms

Complete Patient Online Packet 

Welcome to Premier ENT, thank you for choosing our practice for your Ear, Nose and Throat health care needs. Our goal is to meet your individual needs and to provide quality medical care in a convenient, comfortable setting.


Our office is open five days a week, Monday through Friday 8:30am until 4:30pm. Should you need to contact us during regular hours, just dial (909)793-2500 and follow the prompts to speak with a member of our staff.


On this page you will find a number of online forms for you to read, complete, and sign.


  • Patient Registration
  • Medical History Form
  • Notice of Privacy Policies and your Rights as a Patient


We ask that you arrive at our office 15 minutes prior to your scheduled appointment time.


Please bring with you to the appointment:


  • Your insurance card(s)
  • Your copay
  • A photo ID
  • All of the papers in this packet
  • A current medication list
  • Results from recent lab work or radiology studies (x-ray, CT scan, ultrasound, etc.)


We understand that you have many choices when it comes to finding a healthcare provider, and we are pleased you have chosen Premier ENT, Inc. We look forward to meeting you and providing you with high quality medical care. 


Please complete ALL of the 5 steps on this page.


Step #1 of 5

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Insurance Plans Available

All Major Carriers

Aetna/US Healthcare

Blue Cross

Blue Shield

CIGNA

Healthnet

Humana

Medicare

PHCS

HMO

Aetna/US Healthcare

Blue Cross

Blue Shield

CIGNA

Healthnet

Humana

Medicare

United Healthcare

Group Affiliates

Inland Health Org.

Physicians Health Network

Pinnacle

Prime Care

RYMG

Regal

SBMG

United Family Health Care

Other PPO Plans Accepted

AARP

Admar

Aetna - All

American Postal Workers Union

Affiliated Health Fund

Accountable

Benesight

Carpenters Health & Welfare

Cement Masons

CCN

Cigna

Coventry

EBA&M

First Health

GEHA

Great West

Health Net

IBEW

Laborer / Operating Engineers / AC H&W

Medicare

Megalife

Motion Picture Industry Health

Megalife

Motion Picture Industry Health

Mutual of Omaha

Pacificare

Pipe Trades Union (SCPT)

Physicians Health Network

The Plan Handlers

Principal Life

Religious Comprehensive Trust

Riverside County Foundation

(RCFMC)

Screen Actors Guild

SCAN

Secure Horizons

Sheet Metal Workers

Southwest Administrators

Southern California Drug Benefit Fund

State Farm

Tricare

Teamsters

United Food & Commercial Workers

(UFCW)

UHP

Unicare

Union Labor Life


•  AARP
• Admar
• Aetna - All
• American Postal Workers Union
• Affiliated Health Fund
• Accountable
• Benesight
• Carpenters Health & Welfare
• Cement Masons
• CCN
• Cigna
• Coventry
• EBA&M
• First Health
• GEHA
• Great West


• Health Net
• IBEW
• Laborer / Operating Engineers / AC H&W
• Medicare
• Megalife
• Motion Picture Industry Health
• Megalife
• Motion Picture Industry Health
• Mutual of Omaha
• Pacificare
• Pipe Trades Union (SCPT)
• Physicians Health Network
• The Plan Handlers
• Principal Life
• Religious Comprehensive Trust

• Riverside County Foundation
• (RCFMC)
• Screen Actors Guild
• SCAN
• Secure Horizons
• Sheet Metal Workers
• Southwest Administrators
• Southern California Drug Benefit Fund
• State Farm
• Tricare
• Teamsters
• United Food & Commercial Workers
• (UFCW)
• UHP
• Unicare
• Union Labor Life 

Trust Your Health to an Expert

NEW PATIENT FORMS


In order to expedite the New Patient registration process and to help minimize your waiting time. 

Copies of the required forms can be downloaded below on this website and completed in advance. 


 

Call Us! We're happy to answer your questions:

909-793-2500

Also, you can start by downloading the NEW PDF PATIENT FORM below.

Please plan to arrive 10-15 minutes before your scheduled appointment time in order to complete necessary paperwork.

 This will allow us to establish your medical file before you see your doctor.

Read About Us

YOUR PRIVACY IS IMPORTANT TO US

If you need to request a copy of your medical records from us or another physician, Download an Authorization below to Release Medical Records.

Complete the form and mail to: @ Premier ENT

You may also fax your request to our Medical Records Department at: (909) 793-2502

For further questions regarding medical records, please call: (909) 793-2500

Useful Patient Information

PAYMENT INFORMATION


Co-payments and payment for services not covered by your insurance will be due at your visit. For your convenience, we accept cash, check or all major credit cards. We will also file your claims for all surgical procedures. Remaining balances and deductibles will be billed to you.


If you have questions regarding insurance and payments please contact us at (909) 793-2500


Click below to download PDF:

Trust Your Health to an Expert

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