This is a form with two pages. Once you submit the New Patient Registration part, please go to the Health Questionnaire part using the next button. Thank You.

I consent to the evaluation and treatment of the condition for which I, or my child or dependant, have come to Advanced Allergy & Asthma Associates (AAAAA) and authorize the physicians and other health care providers affiliated with AAAAA to provide such evaluation and treatment. I understand that health care providers in training may be involved in my care and treatment and consent to their involvement. I understand that the practice of medicine is not an exact science and acknowledge that no guarantees have been made to me regarding the likelihood of success or outcomes of any examination, treatment, diagnosis, or test performed at or by AAAAA. I acknowledge and agree that this consent will be applicable to all visits or episodes of evaluation and treatment at AAAAA.

In consideration of the treatment provided at AAAAA to me or my child or dependant, I agree to pay AAAAA for such treatment. If private health insurance, Medicare, Medicaid, other governmental or other insurance programs cover the treatment, I authorize AAAAA to bill any such insurer for all charges incurred in connection with the diagnosis, care, and treatment. My insurance coverage may provide that some amount of the bill will remain my personal responsibility, such as my deductible, co-insurance, or charges not covered by my health insurance, Medicare, Medicaid, or any other programs for which I am eligible. I understand that certain payments may be required at the time of, or in advance of, services being provided. I also understand I will be billed for any charges not paid by my insurer, and I will be responsible for paying them in full on a monthly basis unless payment arrangements have been made in advance through the billing department.

I understand and acknowledge that:

• If I elect to pay for medical treatment in cash, in full, before services are provided, I can request that my health insurance, in any form, not be billed for that service or be notified that the service was provided.

• I am responsible for notification to my insurance company to obtain authorization before service is rendered, and if I do not pre-certify for such services, my benefits may be reduced or lost, but I will still be responsible for paying AAAAA for the services. Any questions I have regarding my health insurance coverage or benefit levels should be directed to my health plan and my certificate of coverage.

• If I do not consent, or later revoke my consent, to the release of my information to any insurer that I have identified, I will be responsible for paying all list charges for the treatment and services received.

• I hereby assign to AAAAA and the professionals involved in my care all my rights and claims for reimbursement under any private health insurance policy, Medicare, Medicaid, or any other programs that I identify for which benefits may be available to pay for the services provided to me and authorize payment for such services to be made directly to AAAAA.

• If I default or do not pay for treatment provided, I acknowledge and agree that AAAAA is entitled to recover the full amount of the debt owed for medical services and is entitled to the right of recovery of all collections expenses, including litigation or arbitration costs, and reasonable attorney’s fees incurred for the purpose of securing payment. Collections agency charges 33% of the amount collected as their fee, AAAAA will add 33% to my bill, and the collections agency will then earn 33% of the amount collected.

• Further information concerning AAAAA financial practices and expectations can be found in the Patient Financial Policy, which has been offered to me and can be found on their website listed at the bottom of this notice.

• I understand that I have the right, and the responsibility, to participate in my care and treatment. I understand that I have the right to be informed about the treatment being recommended and the responsibility to ask questions if I do not understand it. I agree to provide accurate and complete information about my health history and presenting complaint, to agree upon a treatment plan, and follow the plan. I understand that my health care providers will treat me with respect, and I agree to do the same for them.

• I understand that AAAAA will use and disclose my health information for the purposes of treatment, payment, and healthcare operations, as permitted by law. Further information can be found in the Notice of Privacy Practices, which has been offered to me.

• I understand and acknowledge that AAAAA may record medical and other information related to my treatment in paper, electronic, photographic, video, and other formats and that such information will be used in the course of my treatment for payment purposes and to support healthcare operations. I give AAAAA, its employees, and agents consent to exchange information with other health care professionals and providers (for example, physicians, consultants, hospitals, nursing homes, home health agencies, and pharmacies) about my prior and current health conditions to facilitate treatment, or to facilitate discharge planning.

• As applicable, I specifically consent to the release by AAAAA of any and all information, test results, and records regarding my treatment for drug or substance abuse, alcoholism, mental health, HIV or AIDS to 1) my treating physicians and independent professionals and other healthcare professionals and providers, and; 2) any private health insurance plan, Medicare, Medicaid, other governmental insurance program or other third-party payers that I identify to obtain payment for the treatment and services provided to me.

Do any of your relatives have a history of the following diseases? If so please specify the relationship.

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