Consent to Begin Venom Immunotherapy

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:

  • 95145 – Single Venom extract
  • 95147 – Mixed Venom 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 Venom Extract Cost:

The cost of individual starter vials is $300.00 for a single stinging insect (honey bee or wasp), and $504.00 for mixed vespids (combination white-faced hornet, yellow hornet, and yellow jacket). Starter kits consist of six (6) vials per injection. A patient will receive anywhere from one (1) to three (3) injections per shot visit depending on the results of skin testing. Therefore, anywhere from six (6) to eighteen (18) vials may be included in the extract order when initiating venom injections.

After completion of the starter kit, the patient will require refill kits, which also include six (6) vials at the same cost per vial listed above.

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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