Peachtree Allergy & Asthma

Offices & Clinics for Allergies and Asthma

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Patient Information Forms

Step 1 of 9 - Appointment

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Appointment
Date Of Appointment
MM slash DD slash YYYY
Time
Hours :
Minutes
AM/PM
Office*
- Carrollton
- Sharpsburg
- Buckhead
- Vinings
Physician

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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
MM slash DD slash YYYY
Age
Marital Status
Patient Home Phone
Patient Cell Phone
Patient Email Address
Other Doctors
Referring MD
Phone
Email
Fax Phone
Address
Street Address Address Line 2 City State ZIP Code
General Physician
Phone
Email
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

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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
MM slash DD slash YYYY
Business Phone

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Child
Complete this section If the patient is a Child.
Father's Name
Father's Birth Date
MM slash DD slash YYYY
Father's Home Phone
Father's Business Phone
Employer
Father's Occupation
Mother's Name
Mother's Birth Date
MM slash DD slash YYYY
Mother's Home Phone
Mother's Business Phone
Mother's Employer
Mother's Occupation

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Pharmacy
Pharmacy Name
Phone
Fax Number
Address/Location

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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
Date
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

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Verification Of Insurance Benefits
Patient'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 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

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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 Coverage
If 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
Date
If YES, ending date of exclusion period.
MM slash DD slash YYYY
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
- No
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
- No
Phone / Address
Bloodwork
If patient needs blood work, which laboratory does the insurance company contract with?
- Labcorp
- Quest
- Both
- Other
IF Other

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Authorization
Regarding Changes Of Insurance
Initial*
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*
Phone
This field is for validation purposes and should be left unchanged.

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Pollen Count

Privacy Policy

HIPAA full document
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.

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Copyright © 2023 Peachtree Allergy & Asthma Clinic
1800 Peachtree St. NW, Suite 720, Atlanta, GA, 30309
404.351.7520