Consent to Begin Venom Immunotherapy

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.

Venom Extract Cost:

• The number of injections a patient receives is based on skin testing, determining whether one, two or three injections will be given per shot visit. Each injection requires a starter kit of three (3) vials per injection.
• The cost of individual starter vials is $420 for a single stinging insect (honey bee or wasp), and $702 for mixed vespids (combination white-faced hornet, yellow-faced hornet, and yellow jacket).

After completion of the starter kit, the patient will require refill (maintenance) 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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