Allergy & Asthma Care of Fairfield County, Llc

ALLERGY & ASTHMA CARE OF FAIRFIELD COUNTY, LLC

Kenneth Backman, MD Katherine Bloom, MD Suzanne Hines, APRN Jillian Ross, APRN

55 WALLS DRIVE 500 MONROE TURNPIKE

FAIRFIELD, CT 06824 MONROE, CT 06468

Patient Name: ______

First MI Last Suffix

Patient Home Address: ______

Street

______Email Address: ______

Zip City State

Race: ______Language:______Ethnicity: Hispanic/Latino:______Not Hispanic/Latino ______

(optional but requested by Government)

CELL Phone: ______Other Number: ______

Home/Work (please circle)

Sex: M F Date of Birth: ______Social Security Number: ______

Month Day Year

Emergency Contact Name & Number: ______

Primary Care Physician: ______Physician Phone Number: ______

Referred By: ______

INSURANCE CARDHOLDER INFORMATION

Cardholder: ______

First MI Last

Address ONLY if different from patient: ______

Street City State Zip

Home Phone: ______Work: ______

Date of Birth: ______SS Number: ______

Subscriber is the: Mother Father Son Daughter Spouse Self Other—of the patient

(please circle)

If my insurance company requires a referral and I do not obtain a valid referral then services are considered not-covered and I am responsible for payment. It is also my responsibility to pay any co-payment and deductible amounts required by my insurance carrier. Charges for office visits are to be paid at the conclusion of each visit. I authorize the release of any information necessary to determine liability for payment and to obtain reimbursement on any claims. I also request that payment of authorized benefits be made on my behalf. I assign the benefits payable, to which I am entitled, including Medicare, private insurance and other health plans to Allergy & Asthma Care. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered valid as an original. I understand that I am financially responsible for all charges not considered a covered benefit by said insurance. In the case of default payment, I promise to pay any legal interest on the balance due, together with any collection costs and reasonable attorney fees incurred to effect collection of the account or future outstanding accounts. By signing below, I authorize Allergy & Asthma Care to bill my insurance company for services rendered.

______

Signed (patient over 18/parent or guardian) Date

______

Name (please print)

I authorize your office to leave messages on my VM/machine or with: ______

ALLERGY AND ASTHMA CARE OF FAIRFIELD COUNTY

Authorization To Release Medical Information To Family Members

Name of Patient: ______

Date of Birth: ______Account Number: ______

I hereby authorize medical providers and personnel of Allergy and Asthma Care to discuss my protected health information with:

______

Name Relationship

______

Name Relationship

______

Name Relationship

This authorization shall be in force and in effect from ______until

______at which time this authorization to use or disclose this protected health information expires.

Unless specified above, this authorization will expire 365 days from the date of signing. I understand that I have the right to revoke this authorization, in writing, at any time. I understand that such revocation is not effective to the extent that the Practice has relied on the use of disclosure of the protected health information. I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state law. I understand that I have the right to refuse to sign this authorization.

______

Name of Patient (Signature) Name of Patient (Printed)

______

Date