Demographic

Directions:

Please note, there are TWO pages of New Patient Paperwork. Please be sure to hit CONTINUE at the end of this page.

Email address:

EMAIL IS NEEDED TO IDENTIFY PAPERWORK

Patients First Name

Patients Last Name

Patients Date of Birth

Child's First Name

Child's Last Name

Child's Date of Birth

Age:

Patient Social Security Number

This is needed for insurance billing

PHONE

IS THIS A MOBILE PHONE?

YES NO

STREET ADDRESS & APT. #

CITY

STATE

ZIP

PRIMARY CARE M.D ./ D.O. / N.P. / P.A.

PCP TELEPHONE

PRIMARY CARE ADDRESS

CITY/ STATE

REFERRED BY DR:

Please upload patients photo ID

Add file

Please upload a file

Please upload parent/ guardians photo ID

Add file

Please upload a file

PARENT OR GUARDIAN #1 FULL NAME:

Date of Birth

Phone

PARENT OR GUARDIAN #2 FULL NAME:

Date of Birth

Phone

PARENTAL CONSENT FOR MEDICAL TREATMENT OF A MINOR.

I, as the parent or legal guardian, consent to medical treatment for my child by Drs. Lockey, Glaum, Cho, & Pepper, and the medical staff under their direction. I also consent to the prescription of medications as necessary and the administration of treatment and medications as indicated in the clinic under the care of the doctors. The opportunity has been granted to ask any questions I may have and they have been satisfactorily answered.

by typing your name above, you consent to electronic signature

EMERGENCY CONTACT NAME:

EMERGENCY CONTACT TELEPHONE

Do you wish to give the above person permission to speak to Allergy Tampa staff and doctors regarding you/ your child's medical care, including diagnosis and treatment plan?

YES NO

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

IF YOU DO NOT WISH TO COMPLETE, CHECK DECLINE

ETHNICITY:

NOT HISPANIC/LATINO LATINO/HISPANIC

RACE:

AMERICAN INDIAN/ALASKA NATIVE ASIAN WHITE BLACK/AFRICAN AMERICAN HAWAIIAN/OTHER PACIFIC ISLANDER OTHER

OTHER SPECIFIED:

Does the patient have Health Insurance?

Yes No

Primary Health Insurance Name:

Primary Insurance Member ID Number:

Is the patient the Subscriber?

Yes No

Subscriber's Date of Birth:

Subscriber Name:

Insurance Subscriber Social Security Number

*For insurance billing purposes*

Please attach front & back of insurance card. PRIMARY INSURANCE

Add file

Please upload a file

Does the patient have a secondary health insurance?

Yes No

Secondary Health Insurance Name:

Secondary Insurance Member ID Number:

Is the patient the Subscriber?

Yes No

Subscriber's Date of Birth:

Subscriber Name:

Insurance Subscriber Social Security Number

*For insurance billing purposes*

Please attach front & back of insurance card. SECONDARY INSURANCE

Add file

Please upload a file

AUTHORIZATIONS

1. CONSENT FOR MEDICAL TREATMENT: I AUTHORIZE ACADEMIC ASSOCIATES IN ALLERGY, ASTHMA, AND 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 (INCLUDING 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 GIVEN TO RELEASE MEDICAL RECORDS TO OTHER HEALTH CARE PHYSICIANS.

Patient Signature or Responsible Party

By typing your name above you consent to electronic signature

Today's Date:

Financial Policy

The physicians and staff welcome you to our practice. We commit to providing 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 insurance has 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:

You are responsible for informing us of any changes to your insurance policy so that your coverage can be re-verified before 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) are 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 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 RESPONSIBILITIES BY SIGNING BELOW.

Patient Signature or Responsible Party

By typing your name above you consent to electronic signature

Today's Date

There are TWO pages of New Patient Paperwork. Please be sure to CONTINUE to the next page to fully complete your New Patient Paperwork.

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