Insurance Policy Holder
Parent / Guardian Information
Environmental History & Asthma Questionnaire
HIPPA CONSENT FORM
I consent to the use or disclosure of my protected health information by AAACOR for the purpose of diagnosing or providing treatment to me, obtaining payment for my health care bills or to conduct health care operations of AACOR. I understand that diagnoses or treatment of me by AAACOR may be conditioned upon my consent as evidenced by my signature on this document.
I understand I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment or healthcare operations of the practice. AACOR is not required to agree to the restrictons that I may request. However, if AAACOR agrees to a restriction that I request, the restriction is binding on AAACOR and William A. Lanting MD.
I have the right to revoke this consent, in writing, at anytime, except to the extent that AACOR has taken action independence on this consent. My "protected health information" means health information, including my demographic information, collected from me and created or received by my physician, another health care provider, a health plan, my employer or a health care clearing house. This protected health information relates to my past, present or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me.
, give permission to let the AAACOR staff leave medical information in a message on my voice mail. Please list phone number :
If patient is a CHILD, please list other contacts that can accompany your child or Medical information can be disclosed to. If you as an ADULT would like to give permission to anyone to be allowed to discuss your medical information, list them here:
AAACor Financial Policy
Please understand that our financial policies are established to assure the financial resources needed to maintain this
medical office for all our patients. We will work with you to ensure that your medical care does not become a financial burden. We will gladly bill your insurance company for any covered services.
We must emphasize that as a health care provider our relationship is with you, not your insurance company. Your insurance is a contract between you, your employer, and the insurance company. Contact your insurance company and/or your employer’s human resource department with regards to your benefit questions.
Insurance Card(s): We require a copy of your current insurance card upon every visit. We require your signature and a current card with every antigen order also.
Co-payments: Co-payments are due at time of service.
Referrals: If your insurance requires a referral, and you do not provide one at the time of service, you are responsible for any charges incurred.
Cancellations: For all appointments there is a 24 hour cancellation notice requirement.
There is a $25.00 charge for repeated late cancels or no shows.
There is a $50.00 charge for the same on new patient appointments.
If you have health insurance with which we participate:
- We will bill your insurance claim for you.
- We expect any required co-payment at time of service.
- We expect payment of deductible and coinsurance to be paid in full after we have issued you a statement to
be paid within 25 days unless prior payment arrangements have been made.
If you are uninsured or we do not participate with your insurance:
- We require you to sign an uninsured form.
- Payment for total charges are due on the day of your appointment unless you have signed a credit agreement
with our office.
Payment of services is due by the person accompanying any minor child unless other arrangements have been made
in advance. We will not bill two people for care. It is the responsibility of the accompanying adult to pay the amount
due in full, and collect what is owed by others.
We accept payments in cash, check and credit card (VISA, MASTERCARD). Post-dated checks are acceptable within 2
weeks and will be deposited on the check date.
If payment arrangements need to be made, they must be made prior to any service and payment in full must be within 90 days. Accounts over 90 days are subject to collection proceedings.
- There will be a $15 charge for returned checks.
- I have read and accept the terms of this financial policy.
- I understand this pertains to current and any future treatment I receive.
I authorize the release of medical information necessary to process claims or obtain treatment. I authorize payment be made directly to the clinic for services provided. I understand I am responsible for services not reimbursed by my insurance. I understand I am responsible for obtaining referrals for services needed and I will be charged for those services received without a referral in place. If payment arrangements need to be made, they must be made prior to any service or immediately upon receipt of initial statement; payment in full must be made within 90 days. Accounts over 90 days, or any missed payment of your payment arrangement, are subject to collection proceedings.
HIPPA NOTICES OF PRIVACY POLICIES
Our Company Pledge to You
This notice is intended to inform you of the privacy practices followed by Allergy & Asthma Center of the Rockies. It also explains the federal privacy rights afforded to you and the members of your family.
As a medical provider, Allergy & Asthma Center of the Rockies often needs access to health information in order to provide treatment, obtain payment and function in your best interest. We want to assure you that we comply with federal privacy laws and respect your right to privacy. Our staff has been trained to follow these policies. Third parties that we provided access to health information comply with the privacy practices outlined below.
Uses and Disclosure of Health Information
Health Care operations - Your health information may be used, as necessary, to support the day-t-day activities and management of our clinic. For example, information on the services you received may be used to support budgeting and financial reporting, and activities to evaluate and promote quality.
Payment - Your health information may be used to seek payment from your health plan, from other sources of coverage such as automobile insurer, that you may use to pay for services, provided, and the medical condition being treated.
Treatment - Staff members for the purpose of evaluating your health, dianosing medical conditions, and providing treatment, offering treatment alternatives may use your health information.
Appointment Reminders - We may use and disclose medical information to contact you as a reminder that you have an appointment.
As permitted or required by law - We also use or disclose your health information without your written authorization for other reasons as permitted by law. We are permitted by law to share information, subject to certain requirements, in order to communicate information on health-related benefits or services that may be of interest to you, respond to a court order, or provide information to further public health activities (e.g. reporting diseases to state's public health department) without your written authorization. We are also permitted to share health information during a corporate restructuring such as merger, sale, or acquisition. We will also disclose health information about you when required by law, for example, in order to prevent serious harm to you or others.
Pursuant to your Authoriation When required by law, we waill ask for your written authorization before using disclosing your identifiable health information. If you choose to sign an authorization to disclose information, you can later revoke that authorization to cease any future uses or disclosures. In all cases we will do our best to provide only the minimum medical information necessary to fullfill the request, unless otherwise directed to do so.
Right to Inspect and Copy - In most cases you have a right to inspect and receive copies of the health information we maintain about you. If you requst copies , we will not charge for the initial set, but reserve the right to charge for any mailing fees and additional copies. Your request to review your health information must be submitted in writing to the address listed below.
Right to an Accounting of Disclosures - You have the right to receive a list of instances where we have disclosed health information about you for reasons other than treatment, payment, or related administrative purposes.
Right to Amend - If you believe that information within your records is incorrect or if important information is missing, you have a right to request that we correct the existing information or add the missing information. Although the right to request a change exists it does not constitute an adjustment on our behalf. If the request is denied, you will receive a written reason for denial.
Right to Request Restrictions - You may request in writing that we not use or disclose information for treatment, payment, or other administrative purposes except when specifically authorized by you, when required by law, or in emergency circumstances. We will consider your request, but are not legally obligated to agree to those restrictions.
Right to Request Confidential Communications - You have the right to receive confidential communications containing your health information. We are required to accommodate reasonable requests. Forexample, you may ask that we contact you at your place of employment or send communications regarding treatment to analternat eaddress. This request must be made specifically for each instance.
Right to Receive a Paper Copy of this Notice - If you have agreed to accept this notice electronically, you also have a right to obtain a paper copy of this notice from us upon request. To obtain a paper copy of this notice, please contact the person below.
Our Legal Duties
We are required by law to protect the privacy of your information, provide this notice about information practices, and follow the information practices that are described in this notice.
We may change our policies at anytime. Before we make a significant change in our policies, we will provide you with a revised copy of this notice. You can also request a copy of our notice at anytime. For more information about our privacy practices, please call (970) 227-4611.
Complaints If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access to your records, you may contact the number above. You also may send a written complaint t othe U.S.Department of Health and Human Services – Office of Civil Rights.
AAACOR PRE SKIN TEST INSTRUCTIONS
Please read these directions carefully before coming in for your skin test appointment. Prepare to be in the office for several hours that day. Over the counter and prescription drugs may affect skin testing including anti histamines containing cold and allergy medications and sleep aids, histamine blockers and some anti depressants. Allergy testing is performed by scratching liquid antigen son to the patient's back, then allowing 15 minutes for are action to occur. This reaction is a mosquito-like bump that varies in size and redness. The size of the reaction determines if further testing is required. A small amount of allergen is injected into the arms of those that did not show reactions on the back. The size of the reactions helps the physician to determine the patient's allergies and level of sensitivity, which will be discussed after all the testing is completed.
Short Acting Antihistamines - 5 Days Prior to Testing:
Azatadine (Optimine, Trinalin)
Brompheniramine ( Bromfed, Bromphen, Cophene-B, Dallergy-JR, Dimetapp Allergy Liqui-Gels, Lordane products, Nasahist B, Poly-Histine products,Rondec products, Ultrabrom products)
Chlorpheniramine (Aller-Chlor, Atrohist products, Chlor-Trimeton, Duravent DA, Extendryl, Kronofed, Nolamine, Ornade Spansule, Pediacare Allergy Formula, Respar-A.R.M., Sudafed Cold and Allergy, Sinutab Sinus Allergy, Teldrin, Tylenol Cold and Allergy products)
Clemastine (Contac 12 Hour Allergy, Tavist products)
Dexchlorpheniramine (Dexchlor, Polaramine)
Dimenhydrinate (Calm X, Dinate, Dramamine, Dramanate, Hydrate, Triptone Caplets)
Diphenhydramine (Benadryl, Aller Max Caplets, Compoz, Diphen Cough, Diphenhist, Dormarex 2, Genahist, Hyrexin, Nervine Night time Sleep-Aid, Nytol, Siladryl, Sleep-Eze D, Sominex, Twilite Caplets, Tylenol Cold and Allergy products, Unisom Sleep Gels Maximum Strength)
Doxylamine (Tylenol Flu Nighttime, Unisom Nighttime Sleep Aid)
Phenindamine (Nolahist, Nolamine, Poly-Histine products, Triaminic products)
Tripelennamine (PBZ, PBZ-SR, Pelamine)
Hydroxyzine (Atarax, Vistaril)
ANY NIGHT TIME MEDICATIONS: Tylenol pm, Excedrin pm
Long Acting Antihistamines - 7 Days Prior to Testing:
Allegra, Fexofenadine products (5 days)
Astelin nasal spray (7 days)
Astepro nasal spray (7 days)
Claritin/Clarinex, Loratadine products (5 days)
Zyrtec, Cetirizine products (7 days)
Xyzal, Levocetirizine products (7 days)
Alavert products (7 days)
Patanase nasal spray (7days)
Singulair products (7days)
Zyflo products (7days)
ALL ALLERGY EYE DROPS HOMEOPATHIC ALLERGY FORMULAS
Discontinue - Acid Reflux Medications
Acid Reflux/Stomach Drugs (Histamine Blockers) - 48 Hours Prior to Testing:
Nizatidine (Axid), Famotidine (Pepcid), Ranitidine (Zantac), Cimetidine (Tagamet)
Discontinue Only if Okayed by Prescribing Doctor
Other Drugs Including Certain Antidepressants and Anti-Anxiety Agents - 7 Days Prior to Testing:
|Amitriptylene||Hydroxyzine (Atarax, Vistaril)||Trazadone|
|Amoxapine||Imipramine (Tofranil)||Trimipramine (Surmontil)|
|Doxepin (Sinequan)||Protriptylene (Vivactil)|
Do Not Discontinue
Common SSRI Antidepressants - Celexa, Prozac, Paxil and Zoloft
Never stop steroids without asking your prescribing doctor. When taking orally, as an injection or IV, it may reduce your allergy skin test response, so please call to confirm whether your dose is acceptable. Inhaled steroids always continue.
MEDICAL INFORMATION & SYMPTOM REVIEW
List prescribed medication and over-the-counter drugs, such as vitamins and inhalers:
- Past Allergy Therapy
Family Health History (please list what family member)
- Health Habits
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