Privacy Practices

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Patient Name:

Date of Birth:

I, acknowledge that Advanced Allergy & Asthma Associates has provided me a copy of their Notice of Privacy Practices, effective July 1, 2013 (Revised 6/16/2021 3/7/2022). I have had the chance to review this Notice.

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

Signature of Patient/Patient Representative

Date:

Print Name

Relationship to Patient

FOR OFFICE USE ONLY:

We attempted to obtain written acknowledgement of receipt of your Notice of Privacy Practices, but acknowledgement could not be obtained because:

Individual refused to sign Communication barriers prohibited obtaining acknowledgement An emergency situation prevented us from obtaining acknowledgement Other:

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

Staff Name

Staff Signature

Date:

CHOOSE BELOW LOCATION:

9433 N. Beach St, Suite 111 Fort Worth, TX 76244 817-428-7000 (T) * 817-428-7006 (F) 540 E. Southlake Blvd, Suite 140 Southlake, TX 76092 817-410-2111 (T) * 817-410-2113 (F)

I hereby give consent for the patient named above to be treated by providers at Advanced Allergy & Asthma Associates.

I acknowledge that Advanced Allergy & Asthma Associates will file insurance claims on my behalf and hereby authorize the release of any information required to process insurance claims and determine benefits. I authorize payment of benefits directly to Advanced Allergy & Asthma Associates for services rendered. I understand that I am financially responsible for all co-pays, deductibles, co-insurance, non-covered services and unpaid services. I understand that payments are due at the time of service.

I understand that if I require a referral authorization from my insurance company then I am responsible for ensuring that the referral approval/authorization is on file with Advanced Allergy & Asthma Associates before services are rendered. I further understand that in order for continuity of care, I am also responsible for ensuring that there is an up-to-date referral on file AT ALL TIMES. Should a referral authorization/approval expire and in the event that my insurance company will not back date or pay for the services provided by Advanced Allergy & Asthma Associates after said expired referral then I understand that I will be financially responsible for all co-pays, deductibles, co-insurance, non-covered services and unpaid services. I understand that payments are due at the time of service.

I understand that if a minor patient, a parent or legal guardian must be present in the building at all times in order for minor to receive treatment, testing, or injections. (Authorized individuals must be listed on attached Permission to Treat a Minor acknowledgement form)

I understand that delinquent accounts will be referred to outside collection agencies and subject to interest and additional fees.

All medical records are the property of Advanced Allergy& Asthma Associates. Any copies of medical records may be subject to a fee.

I authorize Advanced Allergy & Asthma Associates to call or mail me with communication regarding my healthcare. I understand the privacy risks of phone calls and mail.

I have received and reviewed the Office Policies of Advanced Allergy & Asthma Associates.

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

Signature of Patient/Patient Representative

Date

Print Name

Relationship to patient

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