test gravity forms Patient Information Forms Step 1 of 9 - Appointment 11% AppointmentDate Of Appointment MM slash DD slash YYYY Time Hours : Minutes AM PM AM/PM Office* Carrollton Sharpsburg Buckhead Vinings Physician About The PatientName Prefix Mr.Mrs.MissMs.Dr.Prof.Rev. First Middle Last Sex Male Female RaceSelectAmerican Indian / Alaska NativeAsianBlack African AmericanMore Than One RaceNative HawaiianPacific IslanderWhiteUnreportedOther EthnictyHispanic/LatinononHispanic/LatinoUnreportedAddress Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Date Of Birth MM slash DD slash YYYY AgeMarital StatusSelectSingleMarriedDivorcedWidowedPatient Home PhonePatient Cell PhonePatient Email Address Other DoctorsReferring MD PhoneEmail Fax PhoneAddress Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code General Physician PhoneEmail Fax NumberAddress Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code ContactName of Nearest Local Relative or responsible friend who can be contacted.Name Relationship Phone AdultComplete this section if the patient is an Adult.Adult's Name Occupation Employer Employer's Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Business PhoneSpouseSpouse's Name Birth Date MM slash DD slash YYYY Business Phone ChildComplete this section If the patient is a Child. Father's Name Father's Birth Date MM slash DD slash YYYY Father's Home PhoneFather's Business PhoneEmployer Father's Occupation Mother's Name Mother's Birth Date MM slash DD slash YYYY Mother's Home PhoneMother's Business PhoneMother's Employer Mother's Occupation PharmacyPharmacy Name PhoneFax NumberAddress/Location Person Responsible For BillCheck if same as Patient Name Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Relationship AuthorizationI 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 contentAuthorized Person SignatureDate MM slash DD slash YYYY 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 BenefitsPatient's Name First Middle Last Date Of Birth MM slash DD slash YYYY Policy Holder First Middle Last Policy Holder's DOB MM slash DD slash YYYY (DOB) Date of BirthRelationship To Insured Insurance ID / Member # Group Number Insurance Company Name Insurance Company Claims Mailing Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code PO Box Claim AddressFrom 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 No Type of CoverageSelectPOSHMOPPOIndividual / IndemnityOtherIf Other Effective Date Of Coverage MM slash DD slash YYYY Referral Needed?NOTE It is the patient's responsibility to obtain referrals and make sure they are current and up to date. Yes No Is there a pre-exiting clause? Yes No DateIf YES, ending date of exclusion period. MM slash DD slash YYYY DeductibleA 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 deductibleWhat percentage does your insurance Co pay after deductible Copays After Visitfor specialist Skin TestsIs there a limit on the number of skin tests (CPT Codes 95004, 95024) allowed / covered? Yes No Number of Skin Tests Allowed Skin Test Coverage Covered under the visit Co-pay Applied to deductible CT ScansIs prior authority required for CT scans (CTP: 70486, 70487 or 70488? Yes No Phone / Address BloodworkIf patient needs blood work, which laboratory does the insurance company contract with? Labcorp Quest Both Other IF Other AuthorizationRegarding Changes Of InsuranceInitial*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*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.Patient Signature*Date* MM slash DD slash YYYY Request Your Patient Information Yes, Send Me my Patient Information Email* CommentsThis field is for validation purposes and should be left unchanged. Δ