New Patient Forms

Allergies to Medicine

List all medicine you are currently taking: Prescription and over-the-counter medications (examples: aspirin, antacids) and dietary supplements (example: vitamins) and herbals (examples: ginseng, gingko). Include medications taken as needed (examples: inhalers, nitroglycerin).

Over-the-Counter Medication/Vitamins/Herbals

PATIENT INFORMATION

PHYSICIAN REFERRAL INFORMATION

RESPONSIBLE PARTY INFORMATION

INSURANCE/POLICY HOLDER INFORMATION

AUTHORIZATION & SIGNATURE SECTION

AUTHORIZATION FOR TREATMENT AND RELEASE OF INFORMATION

I hereby give authorization for performance of medical treatment or procedure as may, in the judgment of my attending physician, be deemed necessary. I authorize the office of Allergy & Asthma Consultants of Fairfield County to release any medical information required during the course of examination and treatment and permit payment directly to them any benefits due for their services rendered. I recognize and accept responsibility for the services rendered regardless of insurance coverage. This includes but is not limited to co-insurance, co-payment, deductible, and non-covered services.

PATIENT AGREEMENT

I agree to pay you your regular charges for medical services rendered. My health insurance benefits may pay all or part of your charges. I agree to pay those charges which are not paid by my health insurance. if I do not pay your bill, i agree to pay you your collection costs including attorney's fees and court costs (there will be a $20 charge for all returned checks)

MEDICARE AUTHORIZATION

I request that payment of authorized Medicare benefits be made either to me or on my behalf to Allergy & Asthma Consultants of Fairfield County for any services furnished to me by the physician or supplier. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payables for related services.

CONFIDENTIAL COMMUNICATION

*** Please provide preferred method of communication ***

I hereby request the following means of communication related to my personal health, treatment, diagnosis, test results or billing as noted below:

EMERGENCY CONTACT INFORMATION

HIPAA AUTHORIZATION TO DISCLOSE

I give permission to disclose my personal health information, treatment, diagnosis, test results or billing with:

DISCLAIMER

I understand that I have the right to revoke this authorization, in writing, at any time by sending such written notification to Allergy & Asthma Consultants of Fairfield County 140 Sherman St 3rd Floor Fairfield, CT 06824. I understand that a revocation is not effective to the extent that Allergy & Asthma Consultants of Fairfield County has relied on the use or disclosure of the protected health information.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I hereby acknowledge receipt of the Notice of Privacy Practices from Allergy & Asthma Consultants of Fairfield County.
The Notice of Privacy Practice provides detailed information about how the practice may use and disclose my confidential information. I understand that the practice has reserved a right to change its privacy practices that are described in the notice.

Acknowledgement of Financial Responsibility

Before you make a decision, check with your insurance benefits department. The purpose of this notice is to help you make an informed choice about whether or not you want to receive these services, knowing you may be responsible for payment.

To be performed by Dr. Aimee Altschul-Latzman and associates as deemed necessary.

The results that may be obtained from these tests have not been guaranteed.