DEAR PATIENT

YOUR APPOINTMENT HAS BEEN SCHEDULED FOR:

DATE:_____________________TIME:_____________________________

WITH: HARLEEN K. ANDERSON, M.D.

AT THE FOLLOWING OFFICE: ALTAMONTE / WINTER PARK

FOR THE COMFORT OF OUR ASTHMA PATIENTS, PLEASE DO NOT WEAR PERFUMEOR COLOGNE PRODUCTS.YOUR VISIT WILL LAST BETWEEN 2 ½ TO 3 HRS. BRING OR WEAR SHORT SLEEVEDTOP. IN ORDER TO BETTER SERVE YOU, WE ASK THAT YOU PLEASE COMPLETETHE FOLLOWING BEFORE YOUR SCHEDULED APPOINTMENT AND BRINGTHEM WITH YOU. DO NOT MAIL THESE FORMS.

1.) FILL OUT THE INFORMATION AND MEDICAL HISTORY SHEETS COMPLETELY BEFORE YOUR SCHEDULED APPOINTMENT.

2.) ALONG WITH THESE FORMS, PLEASE BRING WITH YOU:

A. YOUR REFERRAL OR AUTHORIZATION NUMBER IF YOU ARE CONTRACTED WITH AN HMO POLICY. (IF APPLICABLE)

B. NAME OF LABORATORY YOUR INSURANCE IS CONTRACTED WITH. (THIS IS VERY IMPORTANT)

C. YOUR INSURANCE CARD(S.) D. ANY RECENT MEDICAL RECORDS FROM A PREVIOUS PHYSICIAN. (INCLUDING CHEST XRAY REPORTS ONLY & CT SCAN REPORTS ONLY PERTINENT TO THIS VISIT.) NO FILMS.

E. A LIST OF YOUR CURRENT MEDICATIONS OR BRING MEDICATIONS WITH YOU.

F. ANY CO-PAYMENT OR CO-INSURANCE PAYMENT THAT MAY APPLY.

G. DO NOT TAKE ANTIHISTAMINES FOR____ DAYS PRIOR TO APPT. DO NOT STOP ANY OTHER MEDICATION.

WE MUST HAVE THESE IN ORDER TO SEE YOU

1890 SR 436, • Ste. 215 • Winter Park • Florida • 32792 • (407)678-4040 • Fax (407) 678-8154685 Palm Springs Dr. • Ste. 1E • Altamonte Springs • Florida • 32701 • (407) 331-6244 • Fax (407) 331-66447232 Sand Lake Rd. • Ste. 100 • Orlando • Florida • 32819 • (407) 370-3705 • Fax (407) 370-9715

WE REQUIRE A 48 HOURNOTICE FOR

CANCELLATIONS IN ORDER

TO AVOID A $50 CANCELLATION

FEE

DR. A PACKET REV. CFS 1/5/2013

7

ALLERGY, ASTHMA & IMMUNOLOGY ASSOCIATES OF CENTRAL FLORIDA

Home Address:____________________________________

Billing Address: Same as above_____________________

Home Phone:___________________________Cell:____________

Ethnicity:_______________Language preferred:______________

Driver’s Lic. #:____________________Email:_________________

cfs rev. 10/2014

PATIENT INFORMATION

IF PATIENT IS A MINOR PLEASE COMPLETE THIS SECTION

INSURED PARTY and INSURANCE INFORMATION

REFERRAL SOURCE

RELEASE OF INFORMATION and ASSIGNMENT OF BEBFITS

ALLERGY, A STHMA & IMMUNOLOGYA SSOCIATES OF CENTRAL FLORIDA

Central Florida. Allergy, A sthma & Immunology A ssociates of

AAIACF with

Preferred Pharmacy:___________________________________Pharmacy Telephone#:______________________

Allergy, Asthma & Immunology Associates of Central Florida to provide my physician with copies of progressnotes (medical information) concerning my office visit to AAIACF The reason for submission of such informa-tion is to ensure better continuity of patient care.

CFS 12/04/2008

BRIEF (407)-678-4040

ALLERGY HISTORY

PATIENT'S NAME: DOB:

PRIMARY PHYSICIAN: APPT DATE: ADDRESS: LOCATION:

PHYSICIAN:

What is the reason for your visit? How long have these symptoms been present? When are your symptoms worse? all year round spring summer fall winterWhat evaluation have you had? What medications have you tried to control these symptoms? List all the medications that you are now taking. Have you had any allergic reaction to any medication? Please list. Please list all your medical conditions, diagnoses and any surgeries. Please list any medical condition that runs in your family; especially hayfever, asthma or eczema. Mother: Father: Siblings: Children: Other: Do you have any pets at home? Please list.

ALLERGY, A STHMA & IMMUNOLOGY ASSOCIATES OF CENTRAL FLORIDA

AAIACF FINANCIAL POLICYWelcome and thank you for choosing Allergy,Asthma & Immunology Associates of Central Florida for your medicalcare! We are committed to providing you with the highest quality care and achieving desired outcomes through a collaborative effort with you, our patient.

It is important that you understand our nancial policy but equally important that you understand the terms of your medical coverage. Although our staff is very knowledgeable about the various insurance plans with which we participate, you are in the best position to understand the detailed terms of your specic plan. Typically, your insurance carrier provides contact information for their Member Services Department on the back of your insurancecard and we encourage you to contact them with specic benet questions or concerns you may have regardingyour coverage.

Our professional fees have been determined through careful consideration of reasonable and customary chargeswithin our geographical area. We are always happy to discuss with you any questions you may have concerning a bill.

INSURANCEPlease remember that your insurance is a contract between you and your insurance carrier. We will, as a courtesy, bill your insurance and help you receive the maximum allowable benet under your policy. We have found that patients who are involved with their claims process are more successful at receiving prompt and accurate payment for services from the insurance carrier. We do expect patients to be interactive and responsible for communicatingwith your insurance carrier on any open claims.

It is your responsibility to provide all necessary insurance eligibility, identication, authorization, referral information and to notify our ofce of any information changes when they occur. Even a pre-authorization of services does not guarantee payment from your insurance carrier. It is the patient’s responsibility to know if our ofce is participatingor non-participating with their insurance plan. Failure to provide all required information may necessitate patientpayment for all charges. When insurance is involved, we are contractually obligated to collect co-payments, co-insurance, and deductibles, as outlined by your insurance carrier.

UNINSURED PATIENTSIf you do not have medical insurance, we will extend cash pay rates to you. These rates are only if payment is made in full at the time of service.

GENERAL

• Please be prepared to pay for the current visit as well as any past due balance on your account at the time of service unless payment arrangements have been made with the billing department prior to your visit.

• If the patient is a minor, the parent(s) or legal guardian(s) are responsible for payment. In cases where a written court document allows payment for medical costs it is the accompanying parents’ responsibility to obtain reimbursement from the other party involved.

• Social Security Numbers are a necessary part of your nancial information with our ofce. This information, as with any of your medical record, is protected with strict condentiality. We are extending a line of credit by ling insurance for your charges and not collecting in full at the time of service, therefore we must have this information. If you do not wish to provide your social security number we will require payment in full at the time of service.

• Balances that remain outstanding more than 60 days after the date of service (or payment by your insurance carrier) will result in a disruption of immunotherapy services and the cancellation of upcoming appointments. The balance may also be considered for referral to an outside collection agency.

.aaacf-fp cfs rev 10/2014 pg 1 of 2

ALLERGY, ASTHMA & IMMUNOLOGY ASSOCIATES OF CENTRAL FLORIDA

• Accounts referred to an outside collection agency or attorney may be subject to a collection fee, which will be added to the original balance.

• Patients with unpaid delinquent accounts or accounts that have been sent to an outside collection agency will be expected to pay their account in full prior to being seen for a non-emergent visit.

• A $35 fee will be assessed for any returned checks, plus any bank fees. We will require all future payments by cash, cashier’s check or debit/credit card.

• A $50 fee will be applied to new patient accounts for no shows and cancellations with less than 24 hour notice.

• A $30 fee will be applied to established patient accounts for no-shows and cancellations with less than 24 hour notice.

• Our ofce is not party to your divorce decree. The nancial responsibility for minors rests with the parent who signs this nancial policy.

IMMUNOTHERAPYA new vial of allergy extract will be routinely ordered once the patient has utilized approximately 2/3 of his/her vial(s). At the time of preparation of the new vial, the patient (or their medical insurance) will be billed for the vial(s). If the patient does not wish, for either themselves or their medical insurance, to be charged for this extract, he/she must notify the ofce staff in writing and in advance of preparation of the extract thathe/she does not wish to receive a new vial. This will result in his/her injection therapy being delayed or discontinued.

FORM COMPLETION AND FEESWe understand that there may be times when you need a form completed by your physician (i.e. medical leave, disability forms) and we are willing to assist you with these requests. These forms require research and time on the part of the staff and physicians. The volume of requests and complexity involved make it difcult to complete them at the time of your visit. We ask that you allow 7-10 business days for completion of these requests. We charge a form completion fee of $8 per page. Payment in full must be made prior to receiving the completed forms.

MEDICAL RECORDSA medical Records Release form must be lled out for the release of any medical records. Records released to the patient for the rst time will be free. Additional copies can be provided for a fee of $1.00 per page for the rst 25 pages and .25 cents for each page thereafter.

aaacf-fp cfs rev 04/7/2014 pg 2 of 2

ALLERGY & ASTHMA ASSOCIATES OF CENTRAL FLORIDA, P.A.

ACKNOWLEDGEMENT OF RECEIPT OF

FINANCIAL POLICY

Effective Date: February 19, 2014

I have received a copy of the AAACF FINANCIAL POLICY (the “Policy”) The Policy describes the financial terms of the Practice to which I must adhere. I understand that I should read it carefully. Patient Name: __________________________ Signature of Patient or Parent (if minor) ______________________________ Date Signed: ________________________ If Parent signed, Print Parent Name: __________________________

ALLERGY, ASTHMA & IMMUNOLOGY ASSOCIATES OF CENTRAL FLORIDA, P.A.

AAICF

Effective Date: April 11, 2003

I have received a copy of the Notice of Privacy Practices (the “Notice”). The Notice describes how

my health information may be used or disclosed. I understand that I should read it carefully. In

addition, I am aware that the Notice may be changed at any time. I may obtain a revised copy of the

Notice by requesting one at any of our office locations.

Signature of patient or patient representative:________________________________ Date: ______________

Printed name of patient or patient representative:_________________________________________________

Relationship to patient:_______________________________________________________________________

Cfs 3/24/11 A&AS-HIPPA ACK

ALLERGY, ASTHMA & IMMUNOLOGY ASSOCIATES OF CENTRAL FLORIDA, P.A.

ACKNOWLEDGMENT OF RECEIPT OFNOTICE OF PRIVACY PRACTICE