Patient Consent Form

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  • Please list individuals with whom we share your health information including diagnosis, treatment and other health care information including payment. (It is not necessary to list your primary care physician)
  • I hereby authorize Allergy, Asthma, Rheumatology Associates (AARA) to release all information necessary to complete insurance 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.
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