Welcome to the practice of Buffalo Amherst Allergy Associates. P.C.

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Welcome to the practice of Buffalo Amherst Allergy Associates. P.C. Phone: 631-0380 Fax: 836-0773 Thank you for choosing our practice for your allergy and asthma concerns. Please take the time to read over the enclosed information and follow the instructions. ENCLOSED IS A PATIENT QUESTIONNAIRE. PLEASE COMPLETE AND RETURN THE FORMS PRIOR TO YOUR APPOINTMENT. A SELF-ADDRESSED ENVELOPE HAS BEEN ENCLOSED FOR YOUR CONVENIENCE. If you have any questions or concerns about the appointment time or day, please contact our office immediately. If you are unable to keep this appointment, it is important that you contact our office at least 48 hours before your scheduled appointment time. IF YOU FAIL TO DO THIS YOU WILL BE CHARGED A $25.00 FEE. THIS APPOINTMENT WILL RUN APPROXIMATELY 2-3 HOURS IN DURATION. PLEASE PLAN ACCORDINGLY. The information listed below is very important to us. Please review this carefully and follow the appropriate advice. PLEASE READ CAREFULLY 1. Stop all antihistamines (see list on next page), 4 DAYS PRIOR to your appointment. If you are unable to do so you will still be seen in consultation, but we may not be able to do allergy skin tests on the day of your appointment. 2. Bring any sinus, neck, adenoid or chest x-ray reports, or CT scan reports of the sinus or chest you may have had done within the past 2 years with you to your appointment. Your doctor may also fax them. NO FILMS - REPORTS ONLY 3. Bring copies of any blood work that you have had in the previous 12 months with you for your appointment with us. Your doctor may also fax them. 4. Have any reports of prior pulmonary function testing transferred to our office. 5. Have any records from any prior allergy workup and testing transferred to our office. 6. Have any records from any other doctors who have treated this problem transferred to our office. 7. If the patient was hospitalized for this problem or treated in the emergency department, have the records transferred to our office. 8. Please bring or have your pharmacy fax us a list of your current medications you are taking and any antibiotics you have been on in the past 12 months. Our fax number is 836-0773. INSURANCE: BE SURE TO BRING ALL OF YOUR INSURANCE CARDS TO YOUR APPOINTMENT! PHOTO ID WILL BE REQUIRED. IF A MINOR, PARENT/GUARDIAN ID WILL BE REQUIRED. This office participates with most insurance companies in the area. If your insurance is a managed care insurance that requires referrals, it is your responsibility to contact your primary doctor to issue the referral at least one week before your appointment to ensure the referral is here when you arrive. OUR OFFICE WILL NOT CALL YOUR DOCTOR'S OFFICE TO GET YOUR REFERRALS. THIS IS YOUR INSURANCE COMPANY AND IT IS YOUR RESPONSIBILITY TO OBTAIN THE REFERRALS. IF YOU HAVE A GOVERNMENT SUPPLEMENTED HMO (I.E. CHILD HEALTH PLUS. COMMUNITY CARE. FAMILY HEALTHY PLUS) WE MUST HAVE THE REFERRAL IN OUR OFFICE AT THE TIME OF YOUR APPOINTMENT OR WE WILL BE UNABLE TO SEE YOU ON THE DAY YOU ARE SCHEDULED. CO-PAYS, DEDUCTIBLES, SELF PAY: You are responsible for all co-pays, deductibles, and co-insurance balances. COPAYS ARE DUE AT THE TIME OF YOUR VISIT. WE DO NOT BILL FOR THESE. IF YOU ARE UNSURE OF THE CO-PAY AMOUNT, CONTACT YOUR INSURANCE COMPANY PRIOR TO YOUR VISIT. THERE WILL BE A $10 SERVICE FEE FOR ANY OBLIGATION NOT PAID AT THE TIME OF SERVICE. IF YOU HAVE NOT MET YOUR DEDUCTIBLE, A MINIMUM PAYMENT OF 1/2 IS DUE AT THE TIME OF SERVICE. FOR SELF PAY. FULL PAYMENT WILL BE EXPECTED AND TAKEN AT THE TIME OF VISIT. DIVORCED/SEPARATED PARENTS OF MINOR PATIENTS: THE PARENT WHO CONSENTS TO THE TREATMENT OF A MINOR CHILD IS RESPONSIBLE FOR PAYMENT OF SERVICES RENDERED. BUFFALO AMHERST ALLERGY WILL NOT BE INVOLVED WITH SEPARATION OR DIVORCE DISPUTES. PAYMENT: PAYMENTS MAY BE MADE WITH CREDIT CARD, CASH OR CHECKS.

Fax: 836-0773 ALLYSON KIRK, R.P.A.-C NATALIE ASBACH, R.P.A.-C

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