Connecticut Asthma & Allergy Center LLC
Emergency Contact/Relation:
Policy Holder Information:
Policy Holder Information:
is relying on his/her parents medical policy for the partial payment of the charges incurred for services rendered, Patient hereby agrees to allow this medical office and/or its representatives to contact the parent policy holder regarding insurance payments, denials, co-pays, co-insurance, deductibles, balances owed, explanations of benefits, ID numbers, changes in insurers and related issues. I further agree to be financially responsible for payment of all amounts not paid or adjusted off by insurance. In the event of non-payment, I agree to bear the cost of collection including any reasonable legal fees required to obtain payment.
If patient is a minor:
If you have been assigned guardianship of the minor patient, you must present proof of guardianship, such as a court document or DCF paperwork.
hereby acknowledge that I have been offered a copy of Connecticut Asthma & Allergy Center’s Privacy Notice.
I also understand that if Connecticut Asthma & Allergy Center changes or adds to the Privacy Notice, I am entitled to an updated copy upon request.
do not approve the clinical staff of Connecticut Asthma & Allergy Center to leave medical information on my voicemail.
Allergy Center to leave medical information on my voicemail.
I hereby authorize the following people to share any and all confidential information from my/my dependent’s care and treatment provided by Connecticut Asthma & Allergy Center LLC. I understand that this includes medical and/or billing information in written or telephone discussion.
If I wish to rescind this authorization, I understand that I must provide a written note to:
HIPAA Privacy Officer
Connecticut Asthma & Allergy Center LLC
836 Farmington Ave., Suite 207
West Hartford, CT 06119-1551
This is an agreement between Connecticut Asthma & Allergy Center, LLC, and the Patient/Parent of the minor patient named on this form. In this agreement, the words "you," "your," and "yours" mean the Patient/Parent of a minor patient. The word "account" means the account that has been established in your name or your minor child’s name to which charges are made and payments credited. The words "we," "us," and "our" refer to Connecticut Asthma & Allergy Center, LLC.
By executing this agreement, you are agreeing to pay for all services that are received.
Please Initial:
Effective Date: Once you have signed this agreement, you agree to all of the terms and conditions contained herein and the agreement will be in full force and effect.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Your privacy and trust is of the utmost importance to Connecticut Asthma & Allergy Center LLC (CAAC). The providers of CAAC make every reasonable effort to ensure that any information you provide and that is maintained by us is private, confidential, and secure. CAAC clearly and fully discloses our security and privacy practices.
This is to notify you of all uses and disclosures that CAAC may make of your/your dependent’s protected health information (PHI). Please review it carefully. If you have any questions or concerns about this notice, please call HIPAA Privacy Officer at (860) 232-9911.
We are required by law to:
The following categories describe the different ways we may use and disclose your/your dependent’s health information.
We are part of an Organized Health Care Arrangement (OHCA) with the Hartford Physicians Association, Inc. and its other members for the purpose of engaging in certain medical management, utilization review, quality assessment and improvement, and data aggregation activities. We may use and disclose your PHI without your consent in connection with the operations of the OHCA. No member of the OHCA shall be liable or otherwise responsible in any manner for the acts or omissions of any other member of the OHCA by reason of its participation in such arrangement.
Your written authorization is required for all other uses or disclosures of your/your dependent’s health information. CAAC will obtain your written authorization prior to making any disclosures. The authorization will expire after six months. You may revoke your written authorization, in writing, and we will no longer disclose the health information except where we have already taken actions in reliance on your authorization. Psychiatric, HIV/Aids-related information, and substance abuse treatment information requires a specific written authorization. A general authorization for release of medical information will not be sufficient for purposes relating to this information.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Your information will be encrypted.