Patient Registration Form

Full Legal Name:

Address:

City:

Zip:

Home Phone:

Cell Phone:

Work Phone:

Email Address:

(By providing this email you are confirming this is a private address or one with which you are comfortable receiving direct information from us)

Date of Birth:

Age:

Gender:

Male Female Choose not to answer

Social Security No.

Marital Status:

Single Married Divorced Separated

Please provide the following information on the patient: Please select all that apply

Race:

Asian Native Hawaiian or other Pacific Island Black or African American White/Caucasian Hispanic I choose not to report this information

Is the patient of a Hispanic or Latino ethnicity?

Yes No I choose not to report this information

What is the patient’s first language?

English Other I choose not to report this information

If you selected Other, please specify:

Referred By:

PCP Family Member Friend Other

If you selected Other, please specify:

PERSON RESPONSIBLE FOR BILL: Must Complete

It is the policy of this office that the adult presenting the child for treatment is responsible for payment of the patient’s portion at the time of service.

Full Legal Name:

Relationship:

Address:

Home Phone:

Employer:

Position:

Business Address:

Business Phone:

INSURANCE INFORMATION: Must Complete

Add another

EMERGENCY CONTACT INFORMATION

Name:

Relationship:

Phone Number:

Cell Number:

TO WHOM CAN WE SHARE PATIENT INFORMATION WITH

Add another

PHARMACY

Preferred Pharmacy Name:

I authorize the Physicians and staff of Allergy Associates of Western Michigan to access my outside prescribing history and transmit prescription information for me to the pharmacy I have selected.

I understand that:

This is necessary in order to coordinate prescriptions for me and reduce the risk of any possible drug interactions.
Thy Physician may choose to deny treatment if this authorization is not granted, as the inability to access prescribing history or transmit prescription information will restrict treatment options and risk my health and safety.

MEDICAL RECORDS

I hereby authorize the physicians of Allergy Associates of Western Michigan to release medical information including my diagnosis, medical history, and other material contained within those records to referring physicians, hospital, laboratories, and employers (if applicable, as deemed necessary).
I also authorize the release of information necessary for processing my insurance claims.

FINANCIAL POLICY

I authorize payment of benefits, where applicable, directly to these physicians otherwise payable to me for these services.
I understand that if Allergy Associates of Western Michigan participates or is contacted by my insurance company they will:

Bill the insurance company for covered services
Accept cash, checks, credit cards for any fees due directly from the patient
Accept assignment on payments from the insurance company, not including co-pays, co-insurance, deductions, or non-covered services from the patient.

I understand that as a patient of Allergy Associates of Western Michigan:

I accept the responsibility that payment is ultimately my obligation, should I not stay within the parameters of my insurance plan.
Payment is expected at the time of service for any deductibles, co-insurance, co-pays, non-covered services, or self-pay accounts.
I am responsible for obtaining appropriate referrals or authorization from my insurance company or Primary Care Physician prior to the date of service. If this is not obtained, I will be responsible for payment at the time of service.
If my account balance becomes overdue and is placed with a collection agency, I will be responsible to pay for all attorney or collection agency fees associated with my delinquent account.

Print Name:

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient or Responsible Party Signature:

Date:

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