We are pleased to welcome you to South Bay Allergy & Asthma Associates and look forward to providing you with comprehensive allergy and asthma care.
Our staff and doctors make every effort to be timely and we do not double book your appointment time. In order to accommodate the scheduling needs of all patients, kindly confirm your appointment by phone at (310) 371 - 1388 x 11 or by email at least 2 business days prior to your appointment. appointments@southbayallergy.com
Appointment Cancellation and Rescheduling Policy
Notification to reschedule or cancel an appointment must be received in our office at least two business days prior to your appointment.
Failure to do so will result in a $50 fee.
Please be considerate of other patients. Do not eat/snack while in the office. Refrain from using scented lotions/perfumes when visiting our office as these may trigger reactions in some of our patients. Additionally, refrain from using your cell phone while in the office as it is distracting to our staff and other patients.
Please bring your insurance card and photo I.D. to your first visit. It is your responsibility to make sure that we have the most current insurance information on file for you. A statement will be sent to you only if there is an outstanding balance due after your insurance has paid its portion of the claim.
Co-pays, co-insurance and unmet deductibles are due at the time that services are provided. Please be prepared to take care of your financial responsibility at the time of your visit. You will be informed of your responsibility for skin testing prior to the procedure being performed.
Regarding emails: In an effort to be environmentally-friendly and medically efficient our office uses Electronic Medical Records and electronic reminders. Please provide us with an e-mail address so our staff can forward appointment confirmations and practice news alerts to you.
Obtaining diagnostic results: Please do not call the office to review or obtain lab results; these results will be reviewed at the time of your next visit with the doctor. Our nurses and office staff are not trained to interpret lab or radiology results.
Thank you for choosing South Bay Allergy & Asthma
RELEASE OF MEDICAL RECORD In order to ensure proper follow- up and continuity of care, I agree that a copy of my medical record may be released to my physician, a designated referral physician, and /or the provider, if any, who referred me here.
INSURANCE AUTHORIZATION I authorize any holder of medical and other information about me to release to Medicare and its agents, an insurance company, any other third party payer, a state medical assistance agency, or any other governmental or private payer responsible for paying such benefits, any information needed to determine these benefits or benefits for related services. I agree to pay for all charges not covered by a third party payer. I authorize a copy of the authorization to be used in place of the original.
5. Number of pets at home
7. Please describe the patient’s bedroom:
Please check all that apply for family history of allergies
By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
Please list any family members or persons with whom we may leave messages:
When you ask us to fax information to you, it is your responsibility to make sure that the fax number is correct and your confidential information will not be read by anyone else.
You are fully aware that a cell phone is not a secure and a private line.
By signing below, you acknowledge that you have received a copy of this office’s Notice of Privacy Practices and authorize all of the above information.
By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
Your information will be encrypted.