ALLERGY, ASTHMA & IMMUNOLOGY ASSOCIATES OF CENTRAL FLORIDA
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- Laurence Baldwin
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1 ALLERGY, ASTHMA & IMMUNOLOGY ASSOCIATES OF CENTRAL FLORIDA DEAR PATIENT YOUR APPOINTMENT HAS BEEN SCHEDULED FOR: DATE: TIME: WITH: HARLEEN K. ANDERSON, M.D. AT THE FOLLOWING OFFICE: ALTAMONTE / WINTER PARK WE REQUIRE A 48 HOUR NOTICE FOR CANCELLATIONS IN ORDER TO AVOID A $50 CANCELLATION FEE FOR THE COMFORT OF OUR ASTHMA PATIENTS, PLEASE DO NOT WEAR PERFUME OR COLOGNE PRODUCTS. YOUR VISIT WILL LAST BETWEEN 2 ½ TO 3 HRS. BRING OR WEAR SHORT SLEEVED TOP. IN ORDER TO BETTER SERVE YOU, WE ASK THAT YOU PLEASE COMPLETE THE FOLLOWING BEFORE YOUR SCHEDULED APPOINTMENT AND BRING THEM WITH YOU. DO NOT MAIL THESE FORMS. 1.) FILL OUT THE INFORMATION AND MEDICAL HISTORY SHEETS COMPLETELY BEFORE YOUR SCHEDULED APPOINTMENT. 2.) ALONG WITH THESE FORMS, PLEASE BRING WITH YOU: A. YOUR REFERRAL OR AUTHORIZATION NUMBER IF YOU ARE CONTRACTED WITH AN HMO POLICY. (IF APPLICABLE) B. NAME OF LABORATORY YOUR INSURANCE IS CONTRACTED WITH. (THIS IS VERY IMPORTANT) C. YOUR INSURANCE CARD(S.) D. ANY RECENT MEDICAL RECORDS FROM A PREVIOUS PHYSICIAN. (INCLUDING CHEST XRAY REPORTS ONLY & CT SCAN REPORTS ONLY PERTINENT TO THIS VISIT.) NO FILMS. E. A LIST OF YOUR CURRENT MEDICATIONS OR BRING MEDICATIONS WITH YOU. F. ANY CO-PAYMENT OR CO-INSURANCE PAYMENT THAT MAY APPLY. G. DO NOT TAKE ANTIHISTAMINES FOR 7 DAYS PRIOR TO APPT. DO NOT STOP ANY OTHER MEDICATION. WE MUST HAVE THESE IN ORDER TO SEE YOU 1890 SR 436, Ste. 215 Winter Park Florida (407) Fax (407) Palm Springs Dr. Ste. 1E Altamonte Springs Florida (407) Fax (407) Sand Lake Rd. Ste. 100 Orlando Florida (407) Fax (407) DR. A PACKET REV. CFS 1/5/2013
2 ALLERGY, ASTHMA & IMMUNOLOGY ASSOCIATES OF CENTRAL FLORIDA PATIENT INFORMATION Home Address: Home Phone: Cell: Billing Address: Same as above Ethnicity: Language preferred: Driver s Lic. #: IF PATIENT IS A MINOR PLEASE COMPLETE THIS SECTION INSURED PARTY and INSURANCE INFORMATION REFERRAL SOURCE RELEASE OF INFORMATION and ASSIGNMENT OF BEBFITS Central Florida. Allergy, Asthma & Immunology Associates of AAIACF with cfs rev. 10/2014
3 Preferred Pharmacy: Pharmacy Telephone#: Allergy, Asthma & Immunology Associates of Central Florida to provide my physician with copies of progress notes (medical information) concerning my office visit to AAIACF The reason for submission of such information is to ensure better continuity of patient care.
4 ALLERGY, ASTHMA & IMMUNOLOGY ASSOCIATES OF CENTRAL FLORIDA BRIEF (407) ALLERGY HISTORY PATIENT'S NAME: DOB: PRIMARY PHYSICIAN: APPT DATE: ADDRESS: LOCATION: PHYSICIAN: What is the reason for your visit? How long have these symptoms been present? When are your symptoms worse? all year round spring summer fall winter What evaluation have you had? What medications have you tried to control these symptoms? List all the medications that you are now taking. Have you had any allergic reaction to any medication? Please list. Please list all your medical conditions, diagnoses and any surgeries. Please list any medical condition that runs in your family; especially hayfever, asthma or eczema. Mother: Father: Siblings: Children: Other: Do you have any pets at home? Please list. CFS 12/04/2008
5 AAIACF FINANCIAL POLICY Welcome and thank you for choosing Allergy,Asthma & Immunology Associates of Central Florida for your medical care! We are committed to providing you with the highest quality care and achieving desired outcomes through a collaborative effort with you, our patient. It is important that you understand our nancial policy but equally important that you understand the terms of your medical coverage. Although our staff is very knowledgeable about the various insurance plans with which we participate, you are in the best position to understand the detailed terms of your speci c plan. Typically, your insurance carrier provides contact information for their Member Services Department on the back of your insurance card and we encourage you to contact them with speci c bene t questions or concerns you may have regarding your coverage. Our professional fees have been determined through careful consideration of reasonable and customary charges within our geographical area. We are always happy to discuss with you any questions you may have concerning a bill. INSURANCE Please remember that your insurance is a contract between you and your insurance carrier. We will, as a courtesy, bill your insurance and help you receive the maximum allowable bene t under your policy. We have found that patients who are involved with their claims process are more successful at receiving prompt and accurate payment for services from the insurance carrier. We do expect patients to be interactive and responsible for communicating with your insurance carrier on any open claims. It is your responsibility to provide all necessary insurance eligibility, identi cation, authorization, referral information and to notify our of ce of any information changes when they occur. Even a pre-authorization of services does not guarantee payment from your insurance carrier. It is the patient s responsibility to know if our of ce is participating or non-participating with their insurance plan. Failure to provide all required information may necessitate patient payment for all charges. When insurance is involved, we are contractually obligated to collect co-payments, co-insurance, and deductibles, as outlined by your insurance carrier. UNINSURED PATIENTS If you do not have medical insurance, we will extend cash pay rates to you. These rates are only if payment is made in full at the time of service. GENERAL ALLERGY, ASTHMA & IMMUNOLOGY ASSOCIATES OF CENTRAL FLORIDA Please be prepared to pay for the current visit as well as any past due balance on your account at the time of service unless payment arrangements have been made with the billing department prior to your visit. If the patient is a minor, the parent(s) or legal guardian(s) are responsible for payment. In cases where a written court document allows payment for medical costs it is the accompanying parents responsibility to obtain reimbursement from the other party involved. Social Security Numbers are a necessary part of your nancial information with our of ce. This information, as with any of your medical record, is protected with strict con dentiality. We are extending a line of credit by ling insurance for your charges and not collecting in full at the time of service, therefore we must have this information. If you do not wish to provide your social security number we will require payment in full at the time of service. Balances that remain outstanding more than 60 days after the date of service (or payment by your insurance carrier) will result in a disruption of immunotherapy services and the cancellation of upcoming appointments. The balance may also be considered for referral to an outside collection agency.. aaacf-fp cfs rev 10/2014 pg 1 of 2
6 Accounts referred to an outside collection agency or attorney may be subject to a collection fee, which will be added to the original balance. Patients with unpaid delinquent accounts or accounts that have been sent to an outside collection agency will be expected to pay their account in full prior to being seen for a non-emergent visit. A $35 fee will be assessed for any returned checks, plus any bank fees. We will require all future payments by cash, cashier s check or debit/credit card. A $50 fee will be applied to new patient accounts for no shows and cancellations with less than 24 hour notice. A $30 fee will be applied to established patient accounts for no-shows and cancellations with less than 24 hour notice. Our of ce is not party to your divorce decree. The nancial responsibility for minors rests with the parent who signs this nancial policy. IMMUNOTHERAPY A new vial of allergy extract will be routinely ordered once the patient has utilized approximately 2/3 of his/ her vial(s). At the time of preparation of the new vial, the patient (or their medical insurance) will be billed for the vial(s). If the patient does not wish, for either themselves or their medical insurance, to be charged for this extract, he/she must notify the of ce staff in writing and in advance of preparation of the extract that he/she does not wish to receive a new vial. This will result in his/her injection therapy being delayed or discontinued. FORM COMPLETION AND FEES We understand that there may be times when you need a form completed by your physician (i.e. medical leave, disability forms) and we are willing to assist you with these requests. These forms require research and time on the part of the staff and physicians. The volume of requests and complexity involved make it dif cult to complete them at the time of your visit. We ask that you allow 7-10 business days for completion of these requests. We charge a form completion fee of $8 per page. Payment in full must be made prior to receiving the completed forms. MEDICAL RECORDS A medical Records Release form must be lled out for the release of any medical records. Records released to the patient for the rst time will be free. Additional copies can be provided for a fee of $1.00 per page for the rst 25 pages and.25 cents for each page thereafter. aaacf-fp cfs rev 04/7/2014 pg 2 of 2
7 ALLERGY, ALLERGY ASTHMA & ASTHMA & IMMUNOLOGY ASSOCIATES ASSOCIATES OF CENTRAL OF CENTRAL FLORIDA, FLORIDA, P.A. P.A. ACKNOWLEDGEMENT OF RECEIPT OF FINANCIAL POLICY Effective Date: February 19, 2014 I have received a copy of the AAICF AAACF FINANCIAL POLICY (the Policy ) The Policy describes the financial terms of the Practice to which I must adhere. I understand that I should read it carefully. Patient Name: Signature of Patient or Parent (if minor) Date Signed: If Parent signed, Print Parent Name:
8 ALLERGY, ASTHMA & IMMUNOLOGY ASSOCIATES OF CENTRAL FLORIDA, P.A. ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICE Effective Date: April 11, 2003 I have received a copy of the Notice of Privacy Practices (the Notice ). The Notice describes how my health information may be used or disclosed. I understand that I should read it carefully. In addition, I am aware that the Notice may be changed at any time. I may obtain a revised copy of the Notice by requesting one at any of our office locations. Signature of patient or patient representative: Date: Printed name of patient or patient representative: Relationship to patient: Cfs 3/24/11 A&AS-HIPPA ACK
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New Patient Information Form Patient Name: Today s Date: / / Is your problem related to: Job Injury (date) Car Accident (date) Other (date) Address: City: State: Zip: Date of Birth: / / Age: Social Security
New Patient Paperwork Current Insurance Card Valid Driver s License It is also important
Welcome! Thank you for choosing Dr. Christine Stiles to care for your child s plastic surgery needs. This is a satellite office of our Frisco practice that focuses on Pediatric Plastic Surgery. All appointments
Patient's Name: Date of Birth:
AUTHORIZATION TO USE AND/OR DISCLOSE HEALTH INFORMATION Magnolia Pediatrics 2497 Herndon Ave., suite #101, Clovis, CA 93611 Phone: (559) 538-3070 Fax: (559) 538-3071 Patient's Name: Date of Birth: Completion
Please Present Insurance Card at Each Office Visit
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PATIENT INFORMATION Patient First Name Middle Name Last Name Age Birth Date. Mailing Address City State Zip. Street Address City State Zip
PATIENT INFORMATION Patient First Name Middle Name Last Name Age Birth Date Mailing Address City State Zip Street Address City State Zip Home Phone Cell Phone Employer Name (for work comp only) Employer
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NAME (LAST, FIRST, MIDDLE) SSN# BIRTHDATE SEX NAME (LAST, FIRST, MIDDLE) SSN# BIRTHDATE SEX
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All About Kids Pediatric Dentistry
Dr. Courtney Wilson & Dr. Melanie Nesbitt Patient Registration Date: Patient s Name Nickname Birth date Age Sex Patient s Address Contact Phone # street city state zip Father s Name DOB Mother s Name DOB
IDENTIFYING INFORMATION
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TEXAS DIABETES & ENDOCRINOLOGY, P.A. 6500 North Mopac*Bldg. 3, Ste. 200*Austin, TX 78731 5000 Davis Ln*Ste 200*Austin, TX 78749 170 Deep Wood Dr*Ste. 104*Round Rock, Tx 78681 Phone: (512) 458 8400*Fax:
ADDRESS: APT#: CITY: ZIP: IF ANOTHR PHYSICIAN, WHO?
PEDIATRIC PATIENT INFORMATION SHEET ENT & AUDIOLOGY CENTER OF SOUTHLAKE PHONE: (817) 416-9731 FAX: (817) 416-9751 PATIENT NAME (LAST, FIRST, MIDDLE) AGE: SEX: ADDRESS: APT#: CITY: ZIP: PATIENT HOME PHONE:
Today s Date: / / Social Security # Date of Birth: / / Home Address. City State Zip County of Residence. Preferred Phone # ( ) Cell Phone # ( )
Patient Registration Palmetto Digestive & Endoscopy Center 2073 Charlie Hall Blvd., Charleston, SC 29414 Phone: (843) 571-0643 Fax: (843) 571-0311 Name Today s Date: / / Social Security # Date of Birth:
Agnes Kinra, M.D., P.A West 15 th Street Suite 101 Plano, Texas Office: Fax:
Agnes Kinra, M.D., P.A. 4104 West 15 th Street Suite 101 Plano, Texas 75093 Office: 972-596-0006 Fax: 972-596-0904 Dear Patient: Thank you for making an appointment with us. Please arrive 15 minutes before
Patient Registration Form
2130 South 17 th Street Suite 100 Lincoln NE 68502 Phone: 402-454-7454 Fax: 1-402-513-6547 (the 1 must be dialed when faxing to our office) Email: admin@genesispsychiatricgroup.com Patient Registration
Whom May We Thank for Referring You? Primary Care Physician. Insured/Responsible Party. Patient Information. Patient s Spouse/Guardian
Whom May We Thank for Referring You? Name: Other: Newspaper Radio TV Seminar Staff Yellow Pages Other Primary Care Physician Name: Address:_ City: State: Zip: Phone: Insured/Responsible Party Patient Information
WELCOME TO OUR OFFICE. Patient s Name: Today s Date: First Middle Last. Home Address: City: State: Zip: Telephone: Home ( ) Cellular: ( ) Work: ( )
WELCOME TO OUR OFFICE Patient s Name: Today s Date: First Middle Last Home Address: City: State: Zip: Telephone: Home ( ) Cellular: ( ) Work: ( ) Email: Personal Work DOB: Age: SSN#: Ethnic Background:
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Dr. McSwain Dr. Dozier Dr. Ingvoldstad Peachtree Women s Specialists Dr. Roberts Dr. Knoer Today s date Please print and fill out completely. Referred by Account # Legal Name Date of birth Name we should
Green Hills Plastic Surgery Stephen M. Davis, MD, FACS
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WELCOME Thank you for selecting our healthcare team! To help us meet your healthcare needs, please fill out this form completely.
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