Returning Patient Authorizations

In April of 2003, new federal requirements regarding the privacy of information for healthcare patients took effect. HIPAA, the Health Insurance Portability and Accountability Act, requires that all medical providers, insurance companies, and others, put in place controls to ensure that your personal medical information is safe.

Advanced Allergy and Asthma requests that each patient sign this consent form, allowing us to share protected health information with other physician offices and insurance companies. By signing this form, you consent to our use and disclosure of protected health information about your treatment, payment and healthcare operations. You have the right to revoke this consent, in writing, except where we have already made disclosures in reliance on your prior consent.

Our notice of Privacy Practices provides information about how we may use and disclose protected health information about you. You have the right to review our notice before signing this consent.

Authorization to Release Information to Family Members

Many of our patients allow us to share hralth information and results from tests and procedures with family memebers such as their spouse, parents and others. Under the requiredments for HIPAA we are not allowed to give this information to anyone without the patients consent. If you wish for your information to be released, please check YES below and specify which family members(s).

You have been referred to this office due to a specific allergy problem (asthma, sinusitis, hay, fever, hives,  stinging insect allergy, eczema, food or drug allergies, etc.). Advanced Allergy and Asthma is specialty practice, and we work in conjuction with your prumary care or referring physician, to provide you with your necessary medical management.

An allergic investigation includes a detailed history, physical examination, skin tests, pulmonary testing, and a thorough discussion, with all results at the conclusion of the investigation. Any laboratory procedures, If deemed necessary, will be performed outside the office.

It is the responsibility of the patient to make arrangements for all authorizations (If required) once an appointment has been scheduled with Advanced Allergy and Asthma.

We will submit visit charges to your insurance company. Any DEDUCTIBLE, CO-PAYMENT or NON COVERED service will be the responsibility of the patient.

If after reviewing this information, there are additional questions, please do not hesitate to contact our office.