Demographic

Please correct the errors described below.

DUE TO GOVERNMENT MEANINGFUL USE GUIDELINES, WE MUST ASK THESE QUESTIONS. REPORTING THE ENCLOSED INFORMATION IS AT YOUR DISCRETION.

AUTHORIZATIONS

1. CONSENT FOR MEDICAL TREATMENT: I AUTHORIZE ACADEMIC ASSOCIATES IN ALLERGY, ASTHMA & IMMUNOLOGY (AAAAI) TO FURNISH THE NECESSARY MEDICAL TREATMENTS, PROCEDURES, DRUGS, AND SUPPLIES AS ORDERED. I AM AWARE THAT THE PRACTICE OF MEDICINE IS NOT AN EXACT SCIENCE AND ACKNOWLEDGE THAT NO GUARANTEES HAVE BEEN MADE TO ME AS TO THE RESULTS OF TREATMENT, DIAGNOSTIC PROCEDURES, AND EXAMINATIONS.

2. STATEMENT OF FINANCIAL RESPONSIBILITY: I HEREBY AGREE TO PAY AAAAI FOR ALL CHARGES (TO INCLUDE CO-PAYS, DEDUCTIBLES, PERCENTAGES, AND HEALTH SAVINGS ACCOUNTS) AT THE TIME OF SERVICE; HOWEVER, I UNDERSTAND THAT AAAAI MAY ACCEPT ASSIGNMENT OF INSURANCE BENEFITS IN LIEU OF EQUAL AMOUNT OF PAYMENT. THE FULL AMOUNT OF ALL CHARGES NOT PAID BY THE INSURANCE COMPANY WILL ULTIMATELY BE MY RESPONSIBILITY. I REALIZE THAT IF A BALANCE IS DUE NECESSITATING THE USE OF A COLLECTION AGENCY, I AGREE TO PAY ALL COLLECTION COSTS, INCLUDING ATTORNEY FEES AND FEES ON APPEAL.

3. OUR BILLING AND COLLECTION PROCEDURES REQUIRE THAT THE SOCIAL SECURITY NUMBER OF THE INSURED/RESPONSIBLE PARTY BE PROVIDED.

4. I AUTHORIZE AAAAI AND ITS STAFF TO LEAVE MEDICAL INFORMATION PERTAINING TO MY CARE ON ANSWERING MACHINES OR BY VOICE MAIL AND ASSUME RESPONSIBILITY TO NOTIFY THEM WHENEVER INFORMATION MAY CHANGE.

5. NOTICE OF PRIVACY OF PROTECTED HEALTH INFORMATION RECEIVED AND CONSENT IS GIVEN TO RELEASE MEDICAL RECORDS TO OTHER HEALTH CARE PHYSICIANS.

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Financial Policy

The physicians and staff welcome you to our practice. We commit to provide you with the best possible medical care.

Your insurance is a contract between your insurer and you. It is your responsibility to know and understand the terms, guidelines, and limitations of your plan, including obtaining referrals for your visit. Advise us of any changes in your insurance as if it is not updated, it may not be possible to bill insurance at a later date as insurances have deadlines, some at 90 days, and the charges would be yours to pay. Changes in address, phone number, etc. are also required. As required by your insurance carrier, all self-pay, co-insurance and/or deductible is due at the time of the medical service. Payment by Visa, Master Card, Discover, cash, or check is acceptable. An additional fee may be assessed if these payments are not met.

If you have health insurance coverage:

We will submit your claims, however, we must emphasize that as medical providers, our relationship is with you, not your insurance company. Although we attempt to verify your benefits with your insurance policy, please be advised that this is only an estimate of your coverage based on the information given to us at the time of the inquiry. By signing below you confirm that you understand:

  • It is your responsibility to inform us of any changes to your insurance policy so that your coverage can be re-verified prior to your appointment.
  • If your insurance policy requires a referral from your primary care physician, it is your responsibility to have that referral faxed to our office prior to your appointment.
  • Not all services are a covered benefit with all insurance plans.
  • It is your responsibility to be aware of what service(s) is being provided to you and if it is a covered benefit under your insurance policy.
  • You are responsible for any non-covered charges not payable by your insurance policy.
  • Although filing your insurance claims is a courtesy extended to you, all charges are always your responsibility from the date services are rendered.

You will only be sent a statement if your balance exceeds $10.00; you will receive a refund if your credit amount is $10.00 or more which is issued within eight weeks if there are no pending insurance claims. Unpaid balances older than 60 days may be subject to 1.5% interest per month. Returned check fees are added to the account balance and must be paid by cash or credit card within one month. Collection agency/attorney fees apply if the account is turned over with fees up to 35% additionally owed by you.

Insurance claims, including Medicare claims, are submitted daily, followed by secondary claims. We are not contracted with Medicaid.

Charges apply for the completion of FMLA, school forms, etc., as the records must be reviewed as to documentation by the staff and physicians.

If you are unable to keep your appointment, call and give notice 48 hours prior as a fee is assessed. This time is set aside for you and another patient would be able to schedule. Skin test preparation with nurse time allotted is specific for your medical care involving mixing and set-up.

We attempt to verify your benefits but this is only an estimate, plus we have had false information from personnel. Ultimately, it is your responsibility and in your best interest to call.

Affordable Health Care plans: You will be required to provide a credit card which is secured and charged if payment is denied if the premium has not been paid.

If a temporary financial issue arises, connect with us for assistance as we can help with the account.

I HAVE READ, UNDERSTAND, AND WILL COMPLY WITH THE OBLIGATION WITHIN THIS POLICY AND AGREE TO MEET ALL FINANCIAL RESPONSBILITIES BY SIGNING BELOW.

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Liability Release

  1. Given the unusual circumstances about the risks of contracting COVID-19, how it is transmitted and spread, I understand it is unlikely but possible I could be infected with COVID-19 receiving medical care at the offices of Lockey, Fox, Ledford, and Glaum, M.D., P.A., located at 13801 Bruce B. Downs Boulevard and 1906 West Platt Street, Tampa, Florida.
  2. I also understand that the Corporation, its owners and employees will take all reasonable precautions to assure that I or my family members do not contract COVID-19 during my visits.
  3. I acknowledge that I have choices for physicians and specialists to see and choose the above named facilities for my medical care.
  4. Therefore I (we) hereby release from liability Lockey, Fox, Ledford, and Glaum, M.D., P.A. (Corporation) either collectively or individually and all employees from any liability for infection from COVID-19 or consequences from such an infection.
  5. I realize that I should not be seen in the clinic without disclosing to the staff if I think I am sick or have any of the following: a. fever - b. New onset cough - c. New onset shortness of breath - d. New onset aches and pains e. New onset loss of smell or taste
  6. I also agree as I attend the clinic to have my temperature taken and recorded, to properly wear a mask (no exceptions), and maintain distancing as possible and necessary.
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