Your name
Date Of Birth
Your Age
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Your Address
City
State
Zip
Phone Number
Social Security
ChildSingleMarriedDivorcedWidowed
Are you a Medicare Patient? YesNo
Primary Physician Name
Primary Physicians telephone Number
Referred By
Your Pharamacy
Your Pharmacy Number
Name of spouse / parent / Legal Gardian
spouse / parent / Legal Gardian Date of Birth
spouse / parent / Legal Gardian Social Security Number
PATIENTS AND / OR PARENTS EMPLOYMENT INFORMATION:
Your Occupation
Your Occupation Address
Your Occupation phone number
INSURANCE INFORMATION: Please Upload your Insurance Card (Front and Back of card)
Medication List: (If none please write none) Medication Name and Strength / dosage / Frequency/ How is it taken
Medication Name #2 and Strength / dosage / Frequency/ How is it taken (If none please write none)
Medication Name #3 and Strength / dosage / Frequency/ How is it taken (If none please write none)
PLEASE NOTE THAT IT IS YOUR REPONSIBILITY TO BE AWARE OF YOUR INSURANCE PLAN BENEFITS. This includes any requirements regarding referrals, pre-authorization, laboratories to use and / or second opinions (if required)
COPAYS: By law we MUST collect your carrier designated co-pay. This payment is expected at the time of service. Please be prepared to pay the co-pay at each visit.
Please understand that if we have not been advised in advance of your policy requirements or conditions and we provide a service that is not covered, YOU WILL BE RESPONSIBLE FOR THE APPROPRIATE FEES.
Although we do verify benefits, your insurance company doesn’t guarantee coverage of any procedure until a claim is received. These are not our regulations, they are your insurance company’s regulations, and unless you follow them carefully, the insurance company may decline all or part of you claim. If you have any questions regarding your coverage please call your insurance carrier at the customer service number located on your insurance card.
OFFICE POLICY - In order to clarify questions that may arise during the course of treatment, the following policies apply:
Please Check One: I, DoDo not give Dr. Colenda and Staff permission to leave messages concerning my health on my answering machine/voice mail.
When skin testing is done or allergy injections are given, the patient agrees to remain for observation for at least thirty minutes before leaving the office for the patient’s benefit.
Prescriptions will be called into the pharmacy or written out by the doctor. Please note, if the prescription is written out, it will not be called into the pharmacy. Medication will not be prescribed or refilled if it has been more than six (6) months since your last visit.
LABORATORY FEES: This office will not be responsible for any fees/charges incurred for laboratory work not covered by your insurance carrier. Please call them with any questions regarding your benefit
APPOINTMENTS: Please be aware that if you are unable to keep your appointment, kindly give 24 hours notice otherwise a fee of $25.00 will be charged for the time reserved. There will be a $30.00 charge for all returned checks.
PRE-EXISTING CONDITION POLICY If your insurance company states there is a pre-existing clause on your policy, any charges incurred are your responsibility and are payable at the time of service.
I , agree to pay for all charges should my insurance company decide to review my account for pre-existing conditions. I understand that if Allergy Alliance Group is reimbursed for my services by my insurance company that I will receive a refund. However, if the insurance decides that I am subject to pre-existing conditions I will only be reimbursed for the difference, if any, between what the insurance company requires me to pay and what I had paid for the services. By signing below you are agreeing with the above office polices of Allergy Alliance Group; Dr. Maryann J. Colenda.
Due to HIPPA las which protect your medical informationfrom being disclosed to a third party without your permission, including members of your family, we would need your consent in order to do so.
Please give us the name(s) of anyone who would be permitted to speak with the doctor regarding your medical condition and or treatment.
I authorize Dr Maryann Colenda to discuss my medical condition and or treatment with any of the following family members or non family members.
I CERTIFY THIS INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. I WILL NOTIFY YOU OF ANY CHANGES IN THE ABOVE INFORMATION. I AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS AN INSURANCE CLAIM AND REQUEST THAT PAYMENT OF BENEFITS BE MADE TO THE PHYSICIAN UNLESS MY ACCOUNT HAS BEEN PAID IN FULL. I HAVE RECEIVED ALLERGY ALLIANCE GROUPS NOTICE OF PRIVACY PRACTICE.
PATIENT NAME (PRINT)
PATIENT / RESPONSIBLE PARTY SIGNATURE PLEASE INITIAL BELOW