Patient Information

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Insurance/Financial Information (Please submit your insurance cards with this form for scanning)

Primary Insurance

Subscriber's Name

Date of Birth

Relation to Patient

Secondary Insurance

Subscriber's Name

Date of Birth

Relation to Patient

Survey Information

Race

Hispanic

Non-Hispanic

White

Black /Af. American

American Indian

Alaskan Native

Asian

Pacific Islander/Hawaiian Native

Other

Preferred Language

Pharmacy Name

Phone

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Other Physicians

Identification of other physicians involved with my medical care whom I authorize ongoing release of information for continuity of care.

Primary Care Physician Name

Primary Care Physician Address

Primary Care Physician Phone

Referring Care Physician Name

Referring Care Physician Address

Referring Care Physician Phone

The Allergy & Asthma Center offers electronic communications. Electronics communications means talking through text, emails, automated phone calls and the patient portal. Please initial if you would like to participate in electronic communication.

Signature

Use your mouse or finger to sign in the box below.

Email Address

Please list name of person with whom we can discuss your medical care.

Name

Relationship

Date

Patient/Parent/Legal Guardian Signature

Use your mouse or finger to sign in the box below.

I hereby authorize my insurance benefits to be paid directly to the Allergy & Asthma Center, LLC, realizing that i am responsible to pay non-covered services. I hereby authorize the release of any medical information necessary to process insurance claims to my insurance plan, thier agents, or third-party payors and/or goverment agencies.

By signing below, I acknowledge that the information I provided is accurate to the best of my ability.

Date

Patient Signature

Use your mouse or finger to sign in the box below.

Patient Information

Allergy & Asthma Center

Information

if you have an emergency or serious medical problem, who can we contact? Please do not leave blank.

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Insurance/Financial Information (Please submit your insurance cards with this form for scanning)

Survey Information

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