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.
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.
Please complete all insurance information below, in addition to providing a copy of your insurance ID card at each visit, so we can add it to your electronic medical record. Thank you for your anticipated cooperation!
YOU MUST FILL OUT BELOW INFORMATION EVEN IF WE HAVE YOUR CURRENT INSURANCE CARD
ID card must be presented at each visit
Complete below for secondary insurance information
Do you have Secondary Insurance?
***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 compliance 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 annually 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 and agree to the above in its entirety.