Personal Financially Responsible Information (Skip to below if same as above)
Primary Insurance Information
Secondary Insurance Information
In Case of Emergency
The above information is true to the best of my knowledge. I authorize Allergy Institute to bill my insurance and contact me via text/email regarding my appointment
Release of Information to Insurance
By signing the release below, this allows Allergy Institute to expedite the insurance claims for services provided by our providers.
hereby authorize the release of any medical information necessary to process health insurance claims for services provided by Allergy Institute, P.C. This authorizes Allergy Institute P.C. to disclose information to the insurance companies regarding my health and treatment.
Financial Responsibilty and Assignment of Benefits
I understand that the ultimate responsibility and financial obligation for the services rendered by Allergy Institute, P.C. belongs to me.
I understand that I am financially responsible to pay Allergy Institute P.C. its usual charges for all services received through Allergy Institute. P.C., including any balances not covered by my insurance carrier(s). I hereby assign all of my rights to receive any and all insurance proceeds, otherwise payable to me, for coverage(s) provided by my health insurance carrier(s) to Allergy Institute, P.C. and direct that payment of proceeds to Allergy Institute, P.C.
Acknowledgement of Privacy Practices
I acknowledge that there is a “Notice of Medical Information Privacy Rights” that is available at www.allergyinstitutepc.com for me to review or I can be given a paper copy on request.
Consent to Use and Disclose of Protected Health Information
Please fill out the following list, so we can effectively reach you regarding medical appointments, medical care, lab results, billing etc.
I give Allergy Institute, P.C. permission to leave a message on an answering machine. I understand that I have the right to change or revoke this information at any time.
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