Consent to Begin Allergen Immunotherapy (AI)

Allergy Associates of Western Michigan, P.C

Please correct the errors described below.
have consented to begin allergy injections (AI) through Allergy Associates of Western Michigan (AAWM).

AAWM agrees to prepare the extract on my behalf.
Extract is billed at the time it is prepared.

AI administration and extract preparation are separate charges.

I am responsible for contacting my insurance carrier to determine whether extract preparation and AI administration are covered benefits.

Billing codes for insurance are as follows:

  • 95165 - Inhalant allergy extract
  • 95115 - Administration of a single injection
  • 95117 - Administration of two or more injections

A covered benefit does not necessarily mean that benefit will be paid in full by insurance. Occasionally there is a co-pay or deductible for extract preparations and/or administration even if these are covered benefits. The patient is responsible for any charges not paid by insurance.

Approximate Inhalant Allergy Extract cost:

The number of injections a patient receives is based on skin test results, determining whether one, two or three injections will be given per shot visit. Each injection requires a starter kit consisting of five (5) vials of increasing strength.

Starter kit cost:

  • One (1) injection - $975
  • Two (2) injections - $1950
  • Three (3) injections - $2925

After completion of the starter kit, the patient will require refill (maintenance) vials, one for each injection, which cost $325 per vial.

Any outstanding balance must be paid before new extract can be prepared.

Extract is prepared specifically for the individual patient. In the event that extract is prepared and not used, I am still responsible for any outstanding balance.

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