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 cost of an individual starter vial is $750.00. Generally, a starter kit consists of five (5) vials of increasing strength per injection. A patient may receive anywhere from one (1) to three (3) injections per shot visit, depending on the results of skin testing. Therefore, anywhere from five (5) to fifteen (15) vials may be included in the extract order when initiating inhalant AI.

After completion of the starter kit, the patient will require refill (maintenance) vials, each costing $250.00.

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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