Release of Medical Records

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Emergency Contact Information

Release of Information to Other Medical Provider(s)

I authorize my office notes and all testing results be sent to the following medical provider(s):

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Release of information to Insurance Companies, Financial Responsibility & Acknowledge of Privacy Practices

By signing below, this will allow the Allergy Institute to expedite the insurance claims for services provided by our providers. I hereby authorize the release of any medical information necessary to process the health insurance claims for services provided by the Allergy Institute. This authorizes the Allergy Institute to disclose information to the insurance companies regarding my health and treatment. By signing below, I understand that I am financially responsible for all services provided. The Allergy Institute will process claims through my insurance but I understand I am financially responsible for any outstanding balance 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 the coverage(s) provided by my health insurance carrier(s) to the Allergy Institute and direct that payment of proceeds be made directly to the Allergy Institute. By signing below, I understand that I will be responsible for any missed appointments in which a 24-hour notice was not given. There will be a fee of $25.00 fee for any missed standard office visits. There will be a $50.00 fee for any missed office visits with scheduled testing or procedures.

By signing below, I acknowledge that the Allergy Institute’s Privacy Practice Rights has been made available to me if requested. I acknowledge that access to this document is available upon request.

I understand that I have the right to change or revoke this information at any time.

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.

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