New Patient Registration Form
Registration Date: Sunday, October 24, 2021

Patient Registration Form

Personal Information

Preferred Contact Information

Information below will be the ONLY communication we will use to contact you for a COURTESY appointment reminder. Please understand it is your responsibility to know when your appointment is.

Patient Employment Information

Employer Name is required. If patient is a minor or you are unemployed please enter 'Not Available' or 'Not Applicable' in the employer name box.

Emergency Contact Information


***Please fill out ALL insurance information below in addition to providing a copy of your insurance ID card to be scanned into our EMR system. Thank you.

Primary Insurance

ID card must be presented at each visit

Do you have Fidelis?

Secondary Insurance

Complete below for secondary insurance information

Do you have Secondary Insurance?

Parent / Legal Guardian Information

***Please fill out if patient is a minor

Is Patient Under 18yrs of age?

Acknowledgement of Notice of Privacy Practices & Patient Bill of Rights
The Allergy & Asthma Diagnostic Office has posted their "Notice of Privacy Practices" and Patient’s Bill of Rights & Responsibilities in the patient waiting room and on their website at www.allergyaway.com. I understand that upon request, I am entitled to receive a paper copy at any time. I understand the Allergy & Asthma Diagnostic Office reserves the right to change the privacy practices policy to remain in compliant with HIPAA Regulations.
Request for Service Authorization
I hereby authorize providers of the Allergy and Asthma Diagnostic Office to furnish medical services to me and consent to the performance of any diagnostic studies and medical treatment as discussed and mutually agreed to. (or, if I am executing this agreement as a parent or legal guardian of a child)
I hereby authorize the release of any medical information necessary to process any claims to my insurance carrier regarding this and subsequent visits to this office.

I certify that the information given by me in applying for payment by my insurance company is correct and that I will notify AADO with any changes in medical insurance. I authorize and request that payment of benefits by my insurance carrier be made directly to the AADO for services furnished to me or my dependent. I further understand that I may be responsible for all charges not covered by this assignment.
PLEASE NOTE: It is necessary that all requested information be completed prior to treatment. This form will need to be completed each year and when any change in information occurs. Our office will submit to your insurance carrier providing we have all the necessary information, otherwise payment in full may be requested at the time of service. ALL CO-PAYMENTS ARE PAYABLE AT THE TIME OF SERVICE; otherwise a $20.00 billing charge will automatically be added to your account. Thank You.

I have read the above certification, or it has been read to me and I fully understand these statements

PRINTED Name of Patient / Legal Guardian *
Signature of Patient / Legal Guardian * 

Financial Policy

If you have medical insurance, we will help you receive your maximum allowable benefits. In order to achieve these goals, we need your assistance and your understanding of our financial policy.
We require a copy of ALL insurance identification cards and ask that you bring them with you and present them at EACH visit. (Insurances with individual cards, we must have the patient's ID card)

It is the patient's responsibility to secure ALL referrals if your insurance carrier requires one! If a referral is NOT in place PRIOR to your office visit, we may be forced to rescheduled your appointment. We reserve the right to charge for a visit that needs rescheduling due to non-compliance.

Please verify with your insurance carrier if we are participating providers for your insurance. Many insurance provider directories are not up to date. We must emphasize that as medical care providers, our relationship is with you, not with your insurance company. All charges are your responsibility from the date the services are rendered. It is therefore, neither our place, nor our policy to contact insurance companies to establish why they have not made payment or why payment is less than the submitted charges. If an insurance carrier has not paid within 60 days of billing, any unpaid professional fees are due and payable from you. We encourage you to ask for an estimate of the charges you will incur prior to your visit.

PLEASE NOTE: For those insurance companies with whom we have a contract, all co-payments are payable at the time of visit; otherwise a $20.00 billing fee will automatically be added to your account.
***Please be prepared to pay for High Deductible Plan charges and co-insurance at the time of service.
*We accept cash, check, Visa & Mastercard
  • We will submit for most insurance's providing: (we do not treat Workman's Comp, Medicare or Medicaid patients)
    • The patient information form is completely filled out and appointment & financial policies signed.
    • We have a copy of the patient's insurance identification card.
    • We are able to verify coverage with your carrier and have a complete mailing address.
    • If it is your Primary Insurance (we do not routinely bill non-participating secondary insurance's)
    • For non-participating insurances, excluding Tri-Care, we submit claims as a courtesy to our patients.
  • You will receive a billing statement for any unpaid balances, co-insurance's or charges determined not covered under your policy. A $10.00 monthly billing charge will be added to all accounts over 30 days. Any disputes with balances due must be brought within 30 days of the 1st billing or they will not be considered. Accounts not paid within 3 billing cycles, will be send to collection and you will be responsible for collection fees.
  • We realize that temporary financial problems do occur and we encourage you to contact us promptly for assistance in the management of your account. Payment arrangements may be extended in the event of unusual circumstances. To avoid any misunderstandings, we invite you to discuss any financial problems with the Billing office.
(REV. 11-20)

ASSIGNMENT OF BENEFITS:
I have read, understand and agree to the AADO Financial Policy. I authorize the release of any medical information necessary to process my insurance claim(s). For participating insurances, I authorize and request payment of medical benefits directly to my physicians. I agree this authorization will cover all medical services rendered until such authorization is revoked by me. I Understand that No-Show fees are considered a non-covered service and must be paid in full prior to any further appointments being scheduled. I also understand that supplies purchased in this office are considered non-billable to the insurance company and are due at the time of service.
I understand and agree that regardless of my insurance status, I am ultimately responsible for the balance on my account for any professional services rendered and any fees incurred on my account. I will notify you of any changes in my health status or any changes in my insurance status. In the event my account is assigned for collection, I understand that I will be contacted by AADO collection agency of choice and I agree to pay an additional collection fee- the greater of - $25.00 fee or 30% collection fee based on the total amount due as well as any associated attorney fees.
PRINTED Name of Patient / Legal Guardian *
Signature of Patient / Legal Guardian *  

PRINTED Name of Patient / Legal Guardian *
Signature of Patient / Legal Guardian *  

Dear Patients - In order to make your initial visit more productive, it is necessary that all enclosed papers be read prior to your appointment. PLEASE if you have questions, call the office before your initial appointment.

** PLEASE DO NOT WEAR ... PERFUMES or SCENTED COLOGNES, it may irritate or harm our patients with allergies or asthma.   Thank you.

************IMPORTANT INFORMATION************

1. DO NOT TAKE ANITHISTAMINES PRIOR TO VISIT.

Check cold preparations for antihistamines. These are some of the major brands to look for:

*MUST BE OFF 7 DAYS PRIOR TO VISIT:
MULTIVITAMINS, VITAMIN C, Allegra / Allegra-D (Fexofenadine), Zyrtec / Zyrtec-D (Cetirizine), Clarinex / Clarinex-D (Desloratadine), Semprex-D, Pepcid (Famotidine), Zantac (Ranitidine), Cyproheptadine, Xyzal (Levocetirizine), Claritin / Claritin-D / Alavert (Loratadine), Atarax / Vistaril (Hydroxizine), Tagament (Cimetidine), Axid (Nizatidine), Periactin 

MUST BE OFF 3 DAYS PRIOR TO VISIT:
Dimetapp, Tavist / Tavist D, Pantanase, Astelin, Astepro, Azelastin, Benadryl/Diphenhydramine

2. Possible BEE / VENOM reaction patients, if this is the only problem you are coming for, you do not have to stop antihistamines. You will be tested another day.

3. ANTIBIOTIC REACTION - If you are coming for only an antibiotic reaction, you do not have to stop antihistamines. You will be tested another day.

4. If you are scheduled for a breathing test (Pulmonary Function Test)
  * DO NOT TAKE any oral, inhaled or nebulized bronchodilators the day of your appointment.
  Common types are.... Albuterol (Proventil, Ventolin, or ProAir)
                                     Foradil, Maxair, Spiriva, Serevent, Symbicort, Xopenex, Advair
                                     Atrovent (Ipratropium bromide) / Combivent & Combivent respimat

*If you are unsure, please feel free to call.
*However user your inhaler or nebulizer if you are experiencing shortness of breath, difficulty breathing, wheezing, or a sever cough.

5. CONTINUE TAKING any Thophylline's, oral or Inhaled Steroids, Singulair, Accolate.

6. BRING complete list of all medications: if possible bring recent Blood work, Sinus or Chest X-Rays.
YOUR INITIAL VISIT ranges in time from 2-4 hours and includes Consultation, Physical Exam, Allergy Testing and for some patients, Pulmonary Function Testing. Additional testing may be required and completed another day.
if patient has long hair, please wear or bring something to tie it back with. Thank you

PRINTED Name of Patient / Legal Guardian *
Signature of Patient / Legal Guardian *