New Patient Packet Form

Welcome to our practice!

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

PATIENT INFORMATION (Please complete legibly)

Last Name

Middle Name

First Name

Nickname/A.K.A.

Age

Birth Date

Gender

M F

Height

Weight

SSN# of Patient

Home Street Address

City

State

Zip Code

Primary Phone #

Please select

Cell Home Work

Secondary Phone #

Please select

Cell Home Work

Occupation

Employer

Employer Phone #

Preferred Pharmacy Name

Preferred Pharmacy Address

Preferred Pharmacy Phone

Race/Ethnicity

White (Not of Hispanic origin) Black (Not of Hispanic origin) Hispanic Asian/Pacific Islander American Indian/Alaskan Native Other Decline to state

If other, please specify

INSURED PARTY-- If not self

Last Name

Middle Name

First Name

Patients’ Relationship to Insured

Birth Date

SSN# of Insured

Home Street Address

City

State

Zip Code

Primary Phone #

Secondary Phone #

Please select

Home Work

Primary Insurance Information

Primary Insurance Company

Effective Date

Subscriber/I.D. #

Group #

Secondary Insurance Information

Secondary Insurance Company

Effective Date

Subscriber/I.D. #

Group #

Primary Care Physician and Referral Information

Name of Primary Care Physician

Name of Referring Doctor

How Did You Hear About Us? If other than doctor

Website/Search Engine Family/Friend Insurance Company Referral

If website/search engine, please write url:

Emergency Contact

Emergency Contact Name (Last, First)

Telephone #

Relationship

Financial Agreement - Read Before Signing

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.

Signature

Patient or person authorized to consent for patient

Relationship to Patient

(If signing for minor)

Date

Environmental Survey

1. What city do you live in?

Years in Southern California

Previous locations (give dates)

2. Do you live in a…

house condo apt townhome?

How old is it?

3. Does vacationing out of state affect your symptoms?

Yes No

Describe

4. Any known water damage in home?

Yes No

Any air filters in home?

Yes No

Describe

5. Number of pets at home

Dogs

Cats

Birds

Rabbits

other

a. Which pets are indoors?

6. Is the home near a/an…

open field refinery construction site airport other

If other, please specify

7. Please describe the patient’s bedroom:

a. Flooring:

carpet hardwood floors tile other

If carpet, indicate age

b. Window covering:

blinds draperies curtains shades shutters other

If other, please specify

c. Bed(s):

waterbed mattress bunk-beds

If mattress, indicate age

d. Items in bedroom:

stuffed toys books magazines dust collectors Other

If other, please specify

e. Allergy proofing:

allergy encasings HEPA filter

Social History

1. Occupation

Describe any unusual work exposures:

2. Do you currently smoke?

Yes No

Have you smoked in the past?

Yes No

Years

Packs a day

3. Do any household members smoke in the home?

Yes No

In the patient’s bedroom?

Yes No

4. Hobbies/sports:

5. Height:

Weight

Family Histroy

Please check all that apply for family history of allergies

a. Nasal Allergies

Mother

Father

Siblings

Other

Describe

If siblings, please list

If other, please list

b. Asthma

Mother

Father

Siblings

Other

Describe

If siblings, please list

If other, please list

c. Eczema

Mother

Father

Siblings

Other

Describe

If siblings, please list

If other, please list

d. Hives

Mother

Father

Siblings

Other

Describe

If siblings, please list

If other, please list

e. Sinus Problems

Mother

Father

Siblings

Other

Describe

If siblings, please list

If other, please list

f. Immune Disorder

Mother

Father

Siblings

Other

Describe

If siblings, please list

If other, please list

g. Anaphylaxis

Mother

Father

Siblings

Other

Describe

If siblings, please list

h. Food Allergy

Mother

Father

Siblings

Other

Describe

If siblings, please list

If other, please list

i. Autoimmune Disease (i.e. Lupus, Rhumatoid Arthritis)

Mother

Father

Siblings

Other

Describe

If siblings, please list

If other, please list

Do any immediate family members have a history of the following? (Please check if yes):

Diabetes

Heart disease

Tuberculosis

Hypertension

Cancer

If Cancer, please indicate type

Review of Systems

Please describe checked medical issues

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.

Patient Name

Date

Signature

Relationship to patient

Notice of Privacy Practice

Can confidential messages (i.e. appointment reminders, lab results, x-ray results) be left on your telephone answering machine or voice mail?

Yes No

Please list any family members or persons with whom we may leave messages:

Name

Relationship

Name

Relationship

Name

Relationship

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.

Patient’s Name

Date

Signature (Guardian’s if under 18 years)

Relationship

Acknowledgment of Financial Policy

I understand that is my responsibility to verify my insurance policy coverage prior to an office visit. 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.
Payment of co-pays, deductibles, and co-insurance is due at the time service is rendered. All services not covered or approved by the insurance carrier remain my immediate responsibility.
If the physicians of SBAAA are not under contract with my insurance carrier, I understand that it is my responsibility to pay for that portion of services not covered by the plan policy.
I understand that it is my responsibility to notify the business office of any change in my insurance coverage before an appointment date. If I fail to notify the office of a change in my insurance coverage, or the effective date of my new insurance, it is not likely that charges incurred after the effective date of the policy change will be covered and that I will be responsible for these charges.
I understand that some insurance carriers require precertification for lab work done outside of the office (CT scans, x-rays and “blood work”). I understand that it is my responsibility to check with my insurance carrier prior to having the studies performed and to determine if a certain laboratory or x-ray facility must be used. (The SBAAA office will help you as much as possible with this information, please note that policy coverage for procedures performed outside of the office can change without our office being notified).
Notification to reschedule or cancel an appointment must be received in our at least two business days prior to your appointment. Failure to do so will result in a $50.00 fee.
For Medicare patients only: I understand that the SBAAA physicians are Medicare providers and will submit all claims to my insurance carrier. I understand that I will be responsible for annual deductibles and applicable copays.
SBAAA is not a MediCal contracted provider. If I elect to be seen by SBAAA I will be responsible for payment of service.
For patients with HMO insurance only: I understand that my insurance will only pay for services if prior authorization has been obtained for each visit. If I choose to be seen by the physician without the necessary authorization, I understand that I will be responsible for 100% of the charges. I understand that it is not possible for SBAAA to obtain an authorization once the visit has been completed.
For patients with a POS option only: I understand that if I elect to use my POS option, I must continue to use this option for all future visits. I understand that I cannot switch back to my HMO plan and expect to get authorizations for completed visits and procedures.

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.

Signature (parent/guardian where applicable)

Date

Print name

Your information will be encrypted.