New Patient Packet

Patient Name:

Patients Date of Birth:

Today's Date:

Address:

City:

State:

Zip:

Home Phone:

Cell Phone:

Email:

Gender:

Male Female

Marital Status:

Married Single Divorced Other

Preferred Language:

English Other

Ethnicity:

Hispanic/Latino Caucasian African American Asian Prefer not to answer

Employer:

Work Phone:

Socail Security #:

Drivers License #:

Parent/Guardian Information

(if patient is under 18 years of age)

Parent/Guardian Name:

Relation to Patient:

Address:

City:

State:

Zip:

Home Phone:

Cell Phone:

Email:

Employer:

Work Phone:

Social Security #:

Drivers License #:

Insurance Information

Primary Insurance Company:

Address:

City:

State:

Zip:

ID Number:

Group Number:

Guarantor Name:

Guarantor DOB:

Guarantor Employer:

Guarantor Relationship to Patient:

Secondary Insurance Information

Secondary Insurance Company:

Address:

City:

State:

Zip:

ID Number:

Group Number:

Guarantor Name:

Guarantor DOB:

Guarantor Employer:

Guarantor Relationship to Patient:

Other Information

Pharmacy Name:

Address:

City:

State:

Zip:

Pharmacy Phone:

Pharmacy Fax:

Primary Doctor Name:

Address:

City:

State:

Zip:

Doctor Phone:

Doctor Fax:

Reffered by:

How did you hear about us?

Friend

Family

Doctor

Flyer

Community Event

Internet Search

Facebook

www.oit101.org

Financial Policy

I authorize the release of any information necessary to process claims. I request payment of benefits to Freedom Allergy. I understand I am financially responsible for charges not covered by insurance.

If your plan has a co-payment, deductible, and/or co-insurance, you will be expected to pay your portion prior to receiving any service including an office visit and/or immunotherapy. If you are on a high deductible plan, you will be required to pay a minimum of 50% at the time of service until we verify your deductible has been met.

Payment is due at the time of service unless prior financial arrangements have been made with our business office. Any account balance is expected to be paid in full prior to new services being rendered. Should it become necessary for Freedom Allergy to utilize the services of an outside collection agency, you may be held liable for collection agency fees and/or attorney fees.

I understand and agree if care at Freedom Allergy requires a primary care physician referral, it is my responsibility to see that the referral is current prior to receiving care at Freedom Allergy. If no referral is present in advance, I agree to pay for charges at the time of services.

I have read the above Freedom Allergy financial policy and understand my financial responsibility.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient/Responsible Party Signature:

Date:

HIPAA Acknowledgement and Consent Forms

I. Acknowledgement of Practice’s Notice of Privacy Practices

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient’s Rights section describing your rights under the law. You have the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office.

You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor that agreement.

By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment, or healthcare operations. You have the right to revoke this Consent in writing, signed by you. However, such a revocation will not be retroactive.

This Practice provides this form to comply with the Health Insurance Portability and Accountability Act of
1996 (HIPAA).

By signing this form, I understand that:

Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review this Notice.
The Practice reserves the right to change the Notice of Privacy Practices as allowed by law.
The patient has the right to restrict the uses of their information but the Practice does not have to agree to the restrictions.
The patient may revoke this Consent in writing at any time and all future disclosures will then cease.
The Practice may condition receipt of treatment upon execution of this Consent.

This consent was signed by:

Patients Name:

DOB:

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signed (Patient/Legal Representative):

Date:

Relationship to Patient (if other than patient):

II. Request to Receive Confidential Communications by Alternative Means

As provided by Privacy Rule Section 164.522(b), I hereby give permission for Freedom Allergy to communicate to me about appointments, lab results, and/or patient care by phone messages, texts, email, or fax.

Phone Number:

Email Address:

Fax:

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signed (Patient/Legal Representative):

Date:

III. Adult Consent to Share Medical Information

I agree that the Freedom Allergy may disclose certain pieces of my health information to a person of my choosing, since such person is involved with my healthcare or payment relating to my healthcare. I give permission for Freedom Allergy to disclose the following information:

Scheduling appointments

Lab Results

All information regarding assessment, diagnosis, and treatment of my medical condition, including oral immunotherapy, immunotherapy, and other allergic treatments.

Other

If other, please specify:

The indicated information may be disclosed either phone or email to:

Name:

Relationship to Patient:

Phone #:

Email:

Name:

Relationship to Patient:

Phone #:

Email:

Patient's Name (Printed):

DOB:

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient’s Signature:

Date:

*Patient signature is required for patients who are 18 years or older, or who have emancipated minor status, or a special condition as defined by law.

*Patient can cancel this authorization in writing at any time.

Your information will be encrypted.