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Peachtree Allergy & Asthma

Offices & Clinics for Allergies and Asthma

  • Home
  • FAQ
  • Care Providers
    • Carol Ann Wiggins, M.D.
    • Theodore M. Lee, M.D.
    • Amy H. Hirsh, M.D.
    • Ariana D. Buchanan, M.D.
    • Donald C. McLean, M.D.
    • Diane O’Connor, Nurse Practitioner
  • Offices
    • Buckhead Office
    • Carrollton Office
    • Sharpsburg Office
    • Vinings Office
  • Patient Information
    • Allergy Skin Testing
    • Immunotherapy
    • Patient Assistance Application
    • Waiver for Self Pay
  • Conditions We Treat
    • Allergic Rhinitis Nasal Allergies
    • Asthma
    • Eczema Atopic Dermatitis
    • Sinusitis
    • Stinging Insect Allergy
  • Links & Forms
  • Make A Payment
  • Patient Forms

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Patient Information Forms

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  • Appointment

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  • About The Patient

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  • Contact

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

    Complete this section if the patient is an Adult.
  • Spouse

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  • Child

    Complete this section If the patient is a Child.
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  • Pharmacy

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  • Person Responsible For Bill

  • 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
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  • 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.

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  • Verification Of Insurance Benefits

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    (DOB) Date of Birth
  • From the back of the card.
  • Member services / Claims / Benefits
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  • Contact Your Insurance Company


  • You will need to call your insurance company and obtain the following information.
  • Our Tax ID# 58-1306517
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  • NOTE It is the patient's responsibility to obtain referrals and make sure they are current and up to date.
  • If YES, ending date of exclusion period.
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  • 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.
  • What percentage does your insurance Co pay after deductible
  • for specialist
  • Is there a limit on the number of skin tests (CPT Codes 95004, 95024) allowed / covered?
  • Is prior authority required for CT scans (CTP: 70486, 70487 or 70488?
  • If patient needs blood work, which laboratory does the insurance company contract with?
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  • Authorization

    Regarding Changes Of Insurance

  • 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.
  • 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.
  • 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.

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

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HIPAA Privacy Policy with place for signature
Please read before your visit. Thank you.

Patient Information Forms

Patient Forms
Release of medical records

Holiday Hours

Our office will be closed the following holidays:
  • Memorial Day, Monday, May 29
  • Independence Day, July 3 and 4
  • Labor Day, Monday, September 4
  • Thanksgiving, November 22, 23, 24
  • Christmas, To be determind
  • New Year's Eve, To be determind
Peachtree Allergy and Asthma Clinic, PC, does not discriminate on the basis of sex, national origin, disability, or race in its health programs.
Back to Top
  • Home
  • FAQ
  • Care Providers
    • Carol Ann Wiggins, M.D.
    • Theodore M. Lee, M.D.
    • Amy H. Hirsh, M.D.
    • Ariana D. Buchanan, M.D.
    • Donald C. McLean, M.D.
    • Diane O’Connor, Nurse Practitioner
  • Offices
    • Buckhead Office
    • Carrollton Office
    • Sharpsburg Office
    • Vinings Office
  • Patient Information
    • Allergy Skin Testing
    • Immunotherapy
    • Patient Assistance Application
    • Waiver for Self Pay
  • Conditions We Treat
    • Allergic Rhinitis Nasal Allergies
    • Asthma
    • Eczema Atopic Dermatitis
    • Sinusitis
    • Stinging Insect Allergy
  • Links & Forms
  • Make A Payment
  • Patient Forms

Privacy Policy ~ Archive & Sitemap
Copyright © 2023 Peachtree Allergy & Asthma Clinic
1800 Peachtree St. NW, Suite 720, Atlanta, GA, 30309
404.351.7520