New Patient Registration Form

New Patient Forms — Allergy & Asthma Associates of Allen

Notices of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Allergy & Asthma Associates of Allen
977 Raintree Circle, Ste 100, Allen, Texas 75013
Phone: (972) 747-7007 | Fax: (972) 747-7006 | www.allenallergy.com

Uses and Disclosures

Treatment — Your health information may be used by staff members or disclosed to other health care professionals for the purpose of evaluation of your health, diagnosing medical conditions, and providing treatment.

Payment — Your health information may be used to seek payment from your health plan, from other sources of coverage, or from credit card companies that you may use to pay for services.

Healthcare Operations — Your health information may be used as necessary to support the day-to-day activities and management of our practice.

Law Enforcement / Public Health / Research — Disclosures as required by law or under approved research processes, as described in the full Notice.

Other Uses and Disclosures require your specific written authorization. Appointment Reminders may be sent via telephone, email, and/or US mail.

Individual Rights

Request restrictions on use/disclosure of PHI
Receive confidential communications
Inspect and copy protected health information
Amend or submit corrections to PHI
Receive an accounting of disclosures
Receive a printed copy of this notice

Privacy Officer: Dr. Hari Reddy, 977 Raintree Circle, Ste 100, Allen, Texas 75013
Effective Date: on or after November 11, 2020.

This is one combined form. Complete every section below and click Submit All Forms once. All answers are sent together in a single email.

1. Patient Registration & Privacy Acknowledgement

Part 1 of 5 — all parts submit together in one email

Patient Registration

Allergy & Asthma Associates of Allen — New Patient Information

977 Raintree Circle, Ste 100, Allen, Texas 75013 | Phone: (972) 747-7007 | Fax: (972) 747-7006 | www.allenallergy.com

Patient Information

Last Name

First Name

Street Address

City

State

Zip

Home Telephone

Cell Phone

Social Security #

Driver's License #

Date of Birth

Age

Gender

Marital Status

Employer

Work Phone

Work Address

Emergency Contact

In case of emergency notify

Relationship

Phone #

Alternate #

Primary Insurance

Primary Insurance Company

Name of Insured

Relationship to Patient

Identification #

Group #

Insured's Date of Birth

Insured's Employer

Insurance Telephone Number (Benefits / Member Services)

Acknowledgement of Receipt of Notice of Privacy Practices

Our practice reserves the right to modify the privacy practices outlined in this notice. I have reviewed this office's Notice of Privacy Practices, which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of your Notice of Privacy Practices.

Privacy Practices Acknowledgement

I acknowledge that I have reviewed this office's Notice of Privacy Practices.

Name of Patient (Print)

Relationship to Patient (if Guardian)

Date

Typed Signature (Patient or Guardian)

Note: Elementor forms do not support drawn signatures. Typing your full legal name above serves as your electronic signature. A signature pad plugin can be added later if a drawn signature is required.

2. Financial Office Policy

Part 2 of 5 — all parts submit together in one email

Financial Office Policy

Allergy & Asthma Associates of Allen

PAYMENT IS EXPECTED AT THE TIME OF SERVICE
Payment is required at the time services are rendered unless other arrangements have been made in advance. Such payments include coinsurance, co-payments, deductibles, and non-covered services for participating insurance companies. We accept cash, credit/debit cards and personal checks. There is a $25.00 service charge on all returned checks. If the patient is a minor, the parent/guardian who brings the child in for a visit is the responsible party.

INSURANCE / FINANCIAL AGREEMENT
I understand that I am required to give my current insurance card, driver's license, and billing information for insurance to be filed on my behalf. I also understand that I will notify Allergy & Asthma Associates of Allen of any changes in my insurance or billing information. If accurate billing and insurance information is not given then I will be responsible for all charges incurred due to timely filing requirements by my insurance company. I am also responsible for services denied by my insurance company as "non-covered" or "not medically necessary." I authorize the treatment of the person named above and agree to pay for all fees for such treatment. It is agreed that payments will not be delayed or withheld because of insurance coverage or the pending of such claims and that all proceeds of insurance will be assigned to this office. I authorize the release of any medical information necessary to process insurance claims and also request payment of government benefits either to me or the party that accepts assignment below. If we are not contracted with your insurance company, you will be required to pay in full at the time of service.

REFERRALS
If you are on an insurance plan that requires a referral, it is your responsibility to obtain a referral for your visits. The referral must be requested from your primary care physician prior to your appointment in order for insurance to be filed.

APPOINTMENTS
Missed appointments represent a cost to us, to you and to other patients who could have been seen in the time set aside for you. Cancellations are requested 24 hours prior to the appointment. There will be a $25 fee for missed appointments.

FORMS / PRESCRIPTIONS
School/Camp/Physical forms may be mailed, faxed or dropped off to our office. We require 24-48 hours notice for completion. We are happy to mail, fax or hold them for you to pick them up. For written prescriptions, please allow 24 hours for completion.

IMMUNOTHERAPY
All patients receiving allergy injections must wait in the waiting room at least 25 minutes following each injection. We do ask that you pay your co-pay/co-insurance portion when you receive your injection. When a new vial of serum needs to be made, we do require you to clear any balance before processing the vial.

MEDICAL RECORDS
We are dedicated to keeping your medical records confidential and therefore require written authorization for release of medical records. Medical records will be completed within 15 business days as mandated by the Texas Medical Board and may be subject to a processing fee as determined by the Board.

I have read and understand Allergy & Asthma Associates of Allen's Financial Policy. I agree that if it becomes necessary to forward my account to a collection agency, in addition to the amount owed, I also will be responsible for the fee charged by the collection agency for costs of collection.

Patient Full Name

Financial Policy Agreement

I have read and understand the Financial Policy and agree to its terms.

Typed Signature of Responsible Party

Date

3. Medical History

Part 3 of 5 — all parts submit together in one email

Medical History

Please complete all sections as accurately as possible

Name

Today's Date

Gender

Date of Birth

Age

Who referred you to our office?

Primary Care Physician

Reason for visit (Other)

Duration of Condition

List all medications you have tried in the past for allergies

Pharmacy's Address and Phone Number

Allergy Testing & Respiratory History

Have you ever had allergy skin testing?

Date of testing

Physician's name (skin testing)

Have you ever been on allergy shots?

Have you had recurrent sinusitis?

Sinusitis Frequency

Sinusitis Date(s)

Have you had recent pneumonia or bronchitis?

Have you ever had a sinus X-ray or CT?

Pneumonia/Bronchitis Frequency

Sinus Imaging Date(s)

Have you ever been diagnosed with asthma?

Have you ever been hospitalized with asthma?

Have you had to use recent oral or injectable steroids?

Steroids Frequency

Have you been on antibiotics in the last 6 months?

Which antibiotic(s)?

List family members with allergy problems

Have you tested positive for

HIV Hepatitis B Hepatitis C

Are you current on your flu vaccine?

Are you current on general vaccines?

Social History

How long have you lived in your current home? (years)

Is there an obvious mold problem?

If yes, where is the mold in the home?

Type of flooring (include bedroom)

Are you a current smoker/tobacco user?

Packs per day

How long (smoking)?

Are you a former smoker/tobacco user?

If yes, when did you quit?

Prolonged cigarette smoke exposure?

Alcohol consumption

Occupation

Hobbies

Pets

Dog Cat Other

Pets (Other)

They live

Review of Systems

Please check all the symptoms you may have

Sinus

sinus pain forehead sinus pain cheekbone current sinus infection

Ears

congestion pain hearing loss current ear infections

Hematology

lymph node problems bleeding problems bruising problems

Endocrine

weight gain weight loss cold or heat intolerance excessive thirst

Past Medical / Surgical History & Medications

Past Medical History (including chronic problems)

History of Surgery (include sinus surgery)

Do you have any known allergies to medications?

Do you have a known latex allergy?

If yes, please list names and symptoms

Do you have an

Epi-Pen Auvi-Q other

Epinephrine device (other)

All current medications: please list dosage (include allergy medications)

Women Only

Are you currently or might be pregnant?

Are you planning or attempting to become pregnant in the near future?

4. Allergy Skin Test Consent

Part 4 of 5 — all parts submit together in one email

Allergy Skin Test Consent Form

The most often used method for skin testing is the skin prick test. This test exposes you to tiny amounts of items to which you may be allergic. If you are allergic to a substance, a reaction will appear. The doctor and/or nurse will examine any bump that appears and the reddened area around it to decide whether a positive reaction has occurred indicating an allergy.

In the prick test, allergens are applied by tiny scratches that penetrate only the very top layer of skin and rarely draw blood. You may feel only a slight prick or scraping of the skin. If just a few tests are being given, the arm may be used. Reactions are usually seen in ten to twenty minutes if they are going to occur.

Reactions to testing can include an itchy rash that may last for several days and rarely (less than 1% of patients) — hives, swelling, sneezing, shortness of breath/anaphylaxis and light headedness.

The risk and benefits of allergy skin testing have been explained by my doctor and the staff. I am satisfied with the explanation that has been given and do not desire further information. I give permission and consent for this procedure and any treatment needed as a result of this procedure.

** IN ORDER TO AVOID COMPLICATIONS AND/OR INTERACTIONS PLEASE INFORM THE NURSE IF YOU HAVE HAD A MEDICATION CHANGE OR AN ADDITION TO YOUR REGIMEN SINCE THE PREVIOUS OFFICE VISIT.

Patient Name (Please Print)

Date

Skin Test Consent

I give permission and consent for allergy skin testing and any treatment needed as a result of this procedure.

Typed Signature (Patient or Guardian)

Witness Name (office use)

5. Communication Authorizations

Part 5 of 5 — all parts submit together in one email

Confidential Voicemail Authorization

Occasionally, it may become necessary to contact our patient(s) by telephone. In the event you are not available by phone, we will leave detailed voice messages regarding you/your child's treatment. By providing your telephone number(s), you hereby grant Allergy & Asthma Associates of Allen Permission to leave detailed voicemail messages regarding you/your child's treatment.

My Cell Phone (Voicemail)

Voicemail Opt-Out

I do NOT wish to receive voicemails regarding me/my child's treatment

Permission to Share Healthcare Information

I give permission for Allergy & Asthma Associates to provide my personal healthcare information to:

Authorized Person 1 — Name

Authorized Person 1 — Relationship

Authorized Person 2 — Name

Authorized Person 2 — Relationship

E-Mail Messaging Authorization

Email for messaging

Emails sent by Allergy & Asthma Associates of Allen are NOT SPAM.
Emails sent to you will be items regarding you/your child's treatment or appointment.

Email Opt-Out

I do NOT wish to receive emails from Allergy & Asthma Associates of Allen

Text Message Authorization

My Cell Phone (Text)

Text Opt-Out

I do NOT wish to receive text message reminders regarding future appointments

Mailing Address

Street Address

City, State, Zip

Patient's Printed Name

Typed Patient Signature

Date

Patient Date of Birth

Legal Representative's Printed Name

Typed Legal Representative Signature

If Representative, Specify Relationship to Patient