Patient Intake Appointment

Name of Patient
First Last
DOB
MM slash DD slash YYYY
Appointment with Dr.
M.D. On
The office opens at 8:00 AM.
1.Please bring insurance card. If referral is required, make sure it is in place prior to appointment.
2. Bring Cash, Check, or credit card for co-payments, co-insurance, and deductibles. Payment is expected at date of appointment. Esitmated amount
Additional charges if breathing test or allergy testing is done.
3.Arrive 15 minutes early to allow time to complete any paperwork not mailed to you. 4.If you want us to review any Labs done at another Doctor's office, Bring copies of reports with you. 5.We CANNOT promise testing on first visit. 6.Please do not bring children to your appointment unless the child is the patient. 7.If the patient is a minor and not accompanied by a parent, bring complete form:"Parent Designation to permit another person to consent for Health Care." We cannot see the patient without this permission from the parents. This form can be faxed or mailed to you before your appointment. 315-478-2339 is the number to call and ask for the form to be faxed or mailed. 8.Bring a list of ALL medications and include name, strength and dose of all medications.
Initials of responsible party
Please bring this checklist with you to the appointment.

PATIENT INFORMATION FORM
Name
First Middle Last
DOB
MM slash DD slash YYYY
Gender
- Male
- Female
Marital Status
- Single
- Married
- Widowed
- Divorced
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Home
Work
Cell
Referring Physician
Name of Spouse
Responsible Party
- Check If Same As Above
Name
First Middle Last
Relation to Patient
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Home
Work
Cell
Employer
Address
Insurance Information
Primary
Company
Address
ID#
Group#
Subscriber
DOB
MM slash DD slash YYYY
Secondary
Company
Address
ID#
Group#
Subscriber
DOB
MM slash DD slash YYYY

Patient Consent Form
Please list individuals with whom we share your health information including diagnosis. treatment and other health care infonnation irrcluding payment. (lt is not necessary to list your primary care physician)
Name
Phone
Relation
Name
Phone
Relation
I hereby authorize Allergy, Asthma, Rheumatology Associates (AARA) to release all information necessary to complete insaurance forms and to secure payment. I also authorize payment for all surgical/medical services to be sent directly to AARA. I accept responsibility for all medical charges not covered by insurance. I agree to pay any co-pays and/or balances at the time of services unless other arrangements have been made in advance. Correspondence regarding medical charges will be sent to the address of the insurance holder unless other arrangements have been approved in advance. I assume responsibility for all reasonable collection costs, including attorney's fees.
I authorize AARA to send correspondence to the address I have placed on record and to leave messages on my telephone answering machine/voice mail pertaining to appointment, payment issues, test results or other personal care information unless I have provided alternative contact information in advance.
I understand and acknowledge that members of AARA, as well as its employees will have access to my/the patient's medical information as reasonable necessary to carry out continuity of care, treatment plans and recommendations, payment activities and health care operations (including but not limited to quality assurance activities and audits). I consent to the release of any medical information about me (and any other individuals for whom I can give consent) to my health plan and any health care providers involved in caring for me, or to such individuals as reasonable necessary for my health plan or my providers to carry out treatment, payment or health care operations.
Patient (or parent)
Date
MM slash DD slash YYYY
Relationship

Welcome to our practice. It is our pleasure to serve you. We are the oldest subspecialty practice dedicated to the treatment of allergic and immune related diseases in the Central New York area. Our physicians are certified with The American Board of Allergy and Immunology. You can find more about us on our website, www.aarasyr.com.
Genral Information:
- Hours 8AM - 5PM, Mon, Tue, Thr, Fri. Closed Wednesday, with some exceptions.
- Daytime phone: (315) 478-2339 or (315) 478-0502, Fax: (315) 478-0439
- A physicians is always on call and may be reached on beeper at (315) 249-2684.
- Allergy Injections are given Monday, Tuesday and Thursday from 8:00-4:15PM. You must be signed in 4:15PM or you will be asked to return.
- A minor less than 18 years old must be accompanied by a Parent, or parent should complete "Designation to permit another person to consent for Health Care". We can provide you the form upon request.
- We strongly advise that you keep your follow up appointments. Patients who do not cooperate with us should not expect optimal results
- We ask that you notify us of any prescription refills you need at the time of your visit. Patients who do not keep appointments may be asked to schedule one before a prescription is refilled.
- A patient not seen within 6 months may be asked to schedule an appointment before any forms including school forms are processed.
Our Financial Policy
- We participate in the following plans: AETNA, EXCELLUS BC/BS, CDPHP, FIDELIS, MEDICARE, MVP, POMCO, RMSCO, TOTAL CARE, UNITED HEALTH CARE (expect CHP/Medicaid), CIGNA, HUMANA, MULTIPLAN/PHCS, as well as several smaller plans. If you do not see your insurance carrier listed, please contact them to inquire about our participation. This listing may change without notice. Please note that our relationship is with you and not with the Insurance Company.
- We do not participate in Medicaid FFS (Fee for Service). If you have Medicaid FFS as a secondary insurance and your primary insurance does not fully cover the fees, you will be held responsible for the balance.
- It is always the patient's responsibility to make sure that necessary referrals are in place and insurance information is correct and up to date. If it is not, or we cannot verify such information, we reserve the right to reschedule the appointment or you may be held responsible for payment.
- All co-pays are due at the time of service. If you have not met your deductible, payment in full is due at time of service.
- If you have no insurance or we cannot verify insurance, full payment is due at the time of the visit.
- Patients with balances may be asked to reschedule non-urgent visits until payment has been made.
- We ask for the courtesy of 24 hours notice to cancel a scheduled appointment.We reserve the right to charge a $30 fee for patients who fail to give 24 hour notice. This charge is not covered by insurance.
- If you are experiencing financial hardship, please contact us. We will be happy to discuss a payment plan with you.
- Please allow 3 business days to process prescriptions.
- Please allow 10 business days to copy records.
- We reserve the right to discontinue our professional relationship with you if our policies are not followed.
I have reviewed and understand the above and acknowledge receipt of the "Notice of Privacy Practices" booklet. This notice is also available at our wesbite.
Signature of patient (or parent, if patient is a minor)
Date
MM slash DD slash YYYY
Relation to patient (if other than self)

Step 1 of 5

PATIENT INFORMATION FORM

Insurance Information

Primary

Secondary

Patient Consent Form

Review Of Systems

Home Environment