Form - Peachtree Allergy & Asthma Clinic, PC

Patient Information Forms (1)

Step 1 of 11 – Appointment

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This field is for validation purposes and should be left unchanged.

Appointment

Date Of Appointment

Time

Hours

Minutes

AM/PM

Office(Required)

Carrollton

Sharpsburg

Buckhead

Vinings

Physician

About The Patient

Name

Prefix First Middle Last

Sex

Male

Female

Race

Other Ethnicty

Address

Street Address Address Line 2 City State ZIP Code

Date Of Birth

Age

Marital Status

Patient Home Phone

Patient Cell Phone

Patient Email Address

Other Doctors

Referring MD

Phone

Fax Phone

Address

Street Address Address Line 2 City State ZIP Code

General Physician

Phone

Fax Number

Address

Street Address Address Line 2 City State ZIP Code

Contact

Name of Nearest Local Relative or responsible friend who can be contacted.

Name

Relationship

Phone

Adult

Complete this section if the patient is an Adult.

Adult's Name

Occupation

Employer

Employer's Address

Street Address Address Line 2 City State ZIP Code

Business Phone

Spouse

Spouse's Name

Birth Date

Business Phone

Child

Complete this section If the patient is a Child.

Father's Name

Father's Birth Date

Father's Home Phone

Father's Business Phone

Employer

Father's Occupation

Mother's Name

Mother's Birth Date

Mother's Home Phone

Mother's Business Phone

Mother's Employer

Mother's Occupation

Pharmacy

Pharmacy Name

Phone

Fax Number

Address/Location

Person Responsible For Bill

Check if same as Patient

Name

Address

Street Address Address Line 2 City State ZIP Code

Relationship

Authorization

I authorize the Peachtree Allergy and Asthma Clinic, P.C. to furnish medical treatment, including injections and diagnostic tests, to me or my dependent, and I acknowledge instructions for follow-up care. I assign all insurance payments to Peachtree Allergy and Asthma Clinic, P.C. I authorize the use of this form for all insurance submissions relating to myself or my dependents, and a photocopy of this authorization and assignment will be considered as valid as the original. I UNDERSTAND THAT I AM RESPONSIBLE FOR THIS BILL. By the signature below I acknowledge that I have read the above and agree to its content

Authorized Person Signature

Your Name
Your Name
Your Name

Date

I have been given the opportunity to review a copy of Peachtree Allergy and Asthma Clinic’s Notice of Privacy Practices containing a complete description of my rights to privacy and the uses and disclosures of health information.

Authorized Person

Verification Of Insurance Benefits

Patient's Name

First Middle Last

Date Of Birth

Policy Holder

First Middle Last

Policy Holder's DOB

(DOB) Date of Birth

Relationship To Insured

Insurance ID / Member #

Group Number

Insurance Company Name

Insurance Company Claims Mailing Address

Street Address Address Line 2 City State ZIP Code

PO Box Claim Address

From the back of the card.

Insurance Phone #

Member services / Claims / Benefits

Contact Your Insurance Company

You will need to call your insurance company and obtain the following information.

Insurance Representative Giving Benefits Information

Is Our Facility / Physician covered under this plan?

Our Tax ID# 58-1306517

Yes

Type of Coverage

If Other

Effective Date Of Coverage

Referral Needed?

NOTE It is the patient’s responsibility to obtain referrals and make sure they are current and up to date.

Yes

Is there a pre-exiting clause?

Yes

Date

If YES, ending date of exclusion period.

Deductible

A deductible is the out of pocket amount you must pay at the beginning of each year before your insurance starts paying on any charges.

Met to Date

% after deductible

What percentage does your insurance Co pay after deductible

Copays After Visit

for specialist

Skin Tests

Is there a limit on the number of skin tests (CPT Codes 95004, 95024) allowed / covered?

Yes

Number of Skin Tests Allowed

Skin Test Coverage

Covered under the visit Co-pay

Applied to deductible

CT Scans

Is prior authority required for CT scans (CTP: 70486, 70487 or 70488?

Yes

Phone / Address

Bloodwork

If patient needs blood work, which laboratory does the insurance company contract with?

Labcorp

Quest

Both

Other

IF Other

Authorization

Regarding Changes Of Insurance

Initial(Required)

Most insurance companies require that changes be filed within 90 days of the date of services, or the claim will be denied for timely filing. You must provide us with your new insurance information within 30 days to allow time for us to do this. If we are not provided new information in a timely fashion, all charges denied by the insurance company for timely filing will become the patient’s. responsibility.

Initials(Required)

Should your insurance plan / coverage change, it is the patient’s responsibility to contact the insurance company to verify that our clinic is covered or in network with your new insurance plan.

Verify Reading Medications which Interfere with Allergy Skin Tests(Required)

I have read and may have downloaded

Authorization

I have contacted my insurance company and verified the above information. I understand that the information provided does not represent a guarantee of payment.

Benefits for any claim will be provided based on the patient’s eligibility after the claim has been received and processed through my insurance company’s claims department.

Patient Signature(Required)

Your Name
Your Name
Your Name

Date(Required)

Request Your Patient Information

Yes, Send Me my Patient Information

Email(Required)

APPOINTMENT REMINDER AUTHORIZATION

Please indicate below how you would like to receive an appointment reminder.

Mobile Text notifications

I consent to receive reminders by Mobile Text.

I opt-out of Mobile Text reminders.

Mobile Phone Number

PATIENT CONSENT

FOR USE AND DISCLOSURE OF PROTECTED HEALTHCARE INFORMATION (PHI)

I consent to use or disclosure of my protected healthcare information by Peachtree Allergy and Asthma Clinic, P.C. (“Peachtree Allergy”), to carry out treatment, payment and healthcare operations (TPO). By my signature on this document, I understand that diagnosis, treatment, obtaining payment for my healthcare bills from third party payors, and conduct of healthcare operations is conditioned on my consent.

My “protected healthcare information”(PHI) means individually identifiable health information held or disclosed by Peachtree Allergy. This information may be communicated electronically, verbally, or in written form and may be created or received by my physician, another health care provider, a health plan, or a health care clearinghouse. This protected healthcare information relates to my past, present or future physical or mental health or condition and identifies me.

With this consent, Peachtree Allergy may call my home or other alternate location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance, billing, or collection matters, and any calls pertaining to my clinical care, including laboratory results, prescription calls (or faxes) to pharmacists, etc. Peachtree Allergy may also communicate with me at an e-mail address I authorize, using encrypted secure e-mail.

With this consent, Peachtree Allergy may mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards, patient statements, billing and insurance items, etc., or may e- mail these items to me. I have the right to review the Notice of Privacy Practices prior to signing this consent. Peachtree Allergy and Asthma Clinic, P.C. reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by visiting the website at https:/peachtreeallergyclinic.com, or by forwarding a written request to the privacy officer at the location where I am seen.

I have the right to request that Peachtree Allergy restrict how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by such agreement.

By my signature on this form, I consent that Peachtree Allergy and Asthma Clinic, P.C. may use and disclose my PHI to carry out TPO.

I may revoke my consent in writing except to the extent the practice has already made disclosures in good faith upon my prior consent. If I do not sign this consent, or later revoke it, Peachtree Allergy and Asthma Clinic, P.C. may decline to provide treatment to me.

Print Patient Name(Required)

First Last

Signature of Patient or Authorized Representative(Required)

Your Name
Your Name
Your Name

Date(Required)

Print Name of Person Signing Form

Relationship

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

I have been given the opportunity to review Peachtree Allergy and Asthma Clinic’s Notice of Privacy Practices containing a complete description of my rights to privacy and the uses and disclosures of health information. I understand that Peachtree Allergy and Asthma Clinic has the right to change its Notice of Privacy Practices from time to time and that I may contact the practice’s Privacy Officer at any time to obtain a current copy of the Notices of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or health care operations. I also understand that you are not required to agree to my requested restrictions, but if you do agree you are bound to abide by such restrictions.

Patient Name:(Required)

First Last

Signature of Patient or Authorized Person:(Required)

Your Name
Your Name
Your Name

Relationship to Patient:

Date(Required)

Authorization for Electronic Communications

I hereby authorize Peachtree Allergy and Asthma Clinic, P.C. (PAAC) as well as any of its affiliates, agents, contractors, representatives, successors, assigns, and business associates, to contact me (via any telephone numbers, email addresses or other contact points provided to PAAC by me or on my behalf) by the use of any automatic dialing system, by pre-recorded forms of voice/messaging systems, by electronic mail owned or used by the patient, parent, guardian/responsible party/ authorized representative, by text messages, by telephone or cell phone call, for any and all reasons related to the services I (or a patient for whom I am the responsible party, legal guardian and/or authorized representative) receive at PAAC, including but not limited to scheduling, insurance coverage, billing and payment for the services. I am aware that electronic communications may not be absolutely secure in all instances and circumstances despite efforts of electronic serviceproviders, senders, and recipients to maintain security.

In event of conflict between the authorization above and any other authorization or consent I have provided previously, the paragraph above shall control.

I understand that a copy of this authorization will be made available to me and that I can revoke or modify my authorization and /or change my contact information by written notice to PAAC, subject to reasonable processing times.

Patient Name(Required)

First Last

Date of Birth:

Patient /Responsible Party:

Mobile Phone

Relationship to patient:

(Indicate one of the following: Patient; Parent; Legal Guardian; or Other Authorized Party)

Signature of patient / responsible party(Required)

Your Name
Your Name
Your Name

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