New Patient Information Packet

Patient's Name

Date of Birth

Address

City

State

Zip

Home Phone

Work Phone

Cell Phone

Email address

Social Security Number

Employer of Patient

Occupation

Referred By

Primary Care Physician

If other, Please specify

Person Responsible for the Account

Name

Relationship

Address

City

State

Zip

Home Phone

Work Phone

Cell Phone

Email address

Social Security Number

Employer

Occupation

Office Policy Regarding Payment

Co-payments and deductibles are due at the time services are rendered. We will happily submit all Insurance claims as a courtesy to our patients. For those Insurance plans requiring referrals, it is YOUR RESPONSIBILITY TO OBTAIN THE REFERRAL or payment will be expected when services are rendered.

Primary Insurance

Subscriber

Policy/Membership number

Group Number

Claim Address

Telephone Number

Secondary Insurance

Subscriber

Policy/Membership number

Group Number

Claim Address

Telephone Number

I authorize the release of any medical or other information necessary to process an insurance claim. I authorize payment of medical benefits to the undersigned physician for services rendered. A photocopy of the agreement shall be valid as the original.

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

Signature

Date

I recognize that I am responsible for charges incurred for services rendered and agree to pay those charges. (deductibles, co-payments and non-covered services)

Signature

Date

Patient Financial Agreement

Dear Patient,
Thank you for choosing Allergy and Asthma Associates, P.A. for your healthcare needs. We value our relationship with you and would like to tell you about the financial aspects of our services. Some of the information outlined within this policy includes our obligations to comply with insurance, Federal, Privacy, and Fair Collections Acts. Your financial responsibilities related to your healthcare are included as well.

Red Flag Rules
The Federal Trade Commission developed a set of rules to protect consumers against identity theft. In order to protect your identity, we may require a photo ID & Insurance Cards at each visit.

HIPAA
In compliance with HIPAA regulations, we are unable to discuss details of services rendered or to produce an itemized bill for any parties that are not the patient, unless authorized in writing by the patient.

Copayments, Deductibles & Co-Insurance Fees
Fees are based on the complexity of your visit or procedure. When you sign up for your insurance they will notify you of your out of pocket expenses such as a copayment, deductible, or co-insurance. These terms are between you and your insurance and our office is not authorized to make any changes of any kind to these terms. Out-of-pocket expenses will be collected by our staff during your visit and are not contingent upon your receipt of a statement. We accept Visa, Master Card, Discover, and American Express, cash, personal checks, and money orders. We accept secured payments over the phone at (410) 647-2600 or online through our patient portal (https://10921.portal.athenahealth.com/).

Form Completion & Medical Record Copying Fees
We do charge for the completion of school and/or camp medication forms. Attorney requests are subject to Maryland State Medical Records copying fees as outlined in our Records Fees Policy. Our office will notify you when documents are ready for pick up.

Late Arrival to Appointment
If you arrive at your appointment 15 minutes late, or later, we may need to reschedule your appointment.

Missed or Cancelled Appointments
As a courtesy to other patients who need to be seen, if you need to cancel your appointment please notify us at least 24 hours in advance. If we are not contacted 24 hours in advance to cancel an appointment, then a fee of $25.00 will be applied to No Show appointments for existing patients and $75.00 for new patients.

Returned Check Charge
Checks and credit card payments returned for non-Sufficient Funds (NSF) are subject to a $35.00 Fee (in addition to fees from your bank). Cash payments will be expected after more than one NSF fee.

Self- Pay Patients
Our practice will give you an estimate of what will be due. Sometimes it is medically necessary to add services after a care plan has been established. When this occurs, we will notify you of these costs. Payment for all services is due to your visit. In the event you have insurance but do not provide us with the proper referral or authorization from a PCP or insurance, the patient will be responsible for payment.

Payment Plans
In some instances, our office will work with you to develop a plan to assist you in paying outstanding balances with our practice. Our billing department can be reached at (410) 647-2600 or through our patient portal.

Coordination of Benefits
Sometimes you may have more than one insurance company paying for your medical expenses. In order to have the correct insurance pay on your behalf, you must notify us of the correct sequence of primary, secondary, and/or tertiary. Failure to do so could result in all insurances denying your medical claims. If you do not provide us with accurate insurance and coordination of benefits information in a timely fashion you may become responsible for the full charges due.

Non-Payment of Outstanding Accounts
We make many efforts to assist our patients with managing their medical bills. Please contact us if you are having difficulty with payments. Accounts that are not paid in a reasonable amount of time will be sent to an external collection agency. Should the account be referred to a collection agency or an attorney for past due amounts, the guarantor may incur attorney's fees, court costs, and all applicable collections expenses.

Referrals
Some insurance carriers require that you obtain a written referral from your primary care physician for our specialty services. Patients are responsible for obtaining referrals from their Primary Care Physician (PCP) and bringing them to the visit with us. If you have forgotten your referral, we require the completion of our "No Referral Waiver" agreement in order to be treated. We will only perform services and file claims to your insurance for authorized services approved by your insurance carrier's guidelines. Payment for services that have not been approved by a PCP is considered self-pay and payable at the time of service.

Assignment of Insurance Benefits and Third Party Claims
By signing this document you authorize benefits from your insurance company to be made on your behalf to Allergy and Asthma Associates, P.A. for services furnished to you by our providers. You also authorize the release of your medical information necessary to process your insurance claims. If you do not agree with this then our office will be unable to submit insurance claims on your behalf and payment in full will be expected from the patient prior to services being provided.

Financial Attestation
I understand and agree that, regardless of my insurance status, I am ultimately responsible for the financial balance of any services provided to me. I also understand that it is my responsibility to know what the terms of my insurance are and to be in compliance with those terms. Payment is due at the time services are rendered which includes co-payments, deductibles, and co-insurance with my carrier.

I have read the Financial Agreement in this document and agree to the terms outlined. I will notify the office of any changes in my personal address, contact, and/or billing information.

Patient Name / Signature

Date

Permission to leave message

(patient/parent) hereby grant permission to Allergy and Asthma Associates, P.A. to:

Leave detailed messages on my voicemail that may contain my personal health Information

Leave detailed messages with another member of my household/family that may contain my personal health information.

I understand that I will need to provide a written request to Allergy and Asthma Associates, P.A. if I choose to relinquish this permission.

Form completed for Patient / Signature

Date

Patient Name

Date of Birth

Occupation

Current Date

1. Name of person filling out this form and relation to the patient

2. Who suggested you visit us?

3. Who is your primary physician?

4. Is there any other provider who should receive a copy of our report?

5. What is the reason you were referred to us today? (asthma, hay fever, food, bee, medication allergy, etc)

6. What specific problems or symptoms are you having? (sneezing, cough, etc.)

Please answer YES or NO if you have had any of the following within the past year or more:

NOSE

SINUSES

CHEST

EYES

EARS

GASTROINTESTINAL

THROAT & MOUTH

SKIN

CONSTITUTIONAL

Which of the above are of greatest concern to you and impact most on your quality of life?

7. Please provide us with some details of the history of your problem.

When did it begin?

Was it preceded by some other type of allergic condition?

Has there been a trend or variation of symptoms or severity over the years?

8. Have you noticed a pattern with your symptoms? Is it worse in certain locations, months or seasons?

(See Question #15 for foods, bee strings, Latex)

9. What has provided the most relief (avoidance, specific medicines, allergy shots .. )?

10. What hasn't helped?

11. If you have undergone prior allergy evaluation, please list physician, approximate date, and any known details regarding test results and treatment.

If so, where?

12. Describe your smoking history

Average number of packs/day over the years

Numbers of years you have smoked

If applicable, how many years ago did you stop?

13. Please list all current medications, both prescription and over the counter. Also list all herbal and/or nutritional products:

Add Additional Medication, Herbal, or Nutritional Product

14. Please list all known medication allergies and intolerances. Describe the nature of reaction or side effect for each drug and approximate date or age at which the problem surfaced.

15. Please list all known or suspected allergies or intolerances to foods, food additives and colorants, stinging insect venom, and latex (natural rubber) products. Describe the nature of the reaction and approximate date or age at which the problem surfaced.

16. Have you had contact allergies to poison ivy, adhesives, metals, cosmetics, etc.? Describe

18. Please describe your routine for regular exercise

19. Home Environment

Age of Home

Rent

Own

Number of indoor cats?

For how long?

Number of indoor dogs?

For how long?

Other furred pets in home?

For how long?

If cats or dogs were present only in past, how long has it been since such pets were in the home?

What type of animal?

Number of occupants who ever smoke in the home?

Relationship of smoker(s) to patient?

Your bedroom

If so, how many other children in attendance?

Pets at daycare?

Other exposure to pets outside the home? (Friends, neighbors, relatives)

If you live much of the year in a college dorm or apartment, please comment on that setting with the above issues in mind

Are there any particular concerns regarding either the home or work setting not addressed above? (e.g., mouse or cockroach infestations, water damage, mold growth, leaky roof, poor ventilation, etc.)

20. Review of Systems (Have you had any of the following within the past year?)

New Patient Information Packet

Person Responsible for the Account

Office Policy Regarding Payment

Patient Financial Agreement

Permission to leave message

NOSE

SINUSES

CHEST

EYES

EARS

GASTROINTESTINAL

THROAT & MOUTH

SKIN

CONSTITUTIONAL

Your bedroom

HEART

Musculoskeletal

Neuropsychiatric

Endocrine

Blood / Lymphatic

Genitourinary

Lungs

Liver

For Children Specifically