Patient Information

Insurance Information

Please include a copy of patient’s insurance card, front and back, with the patient packet.



Front




Back




Financial Policy

Thank you for choosing us for your health care needs. We are dedicated to providing you with the best possible health care and service. We consider the understanding of your financial responsibilities an essential part of your care.

Payment is required for all services AT THE TIME OF SERVICE, unless your services are covered by a contracted insurance. Self-pay patients will receive a discount on applicable services only if they pay at the time of service. According to the American Medical Association, you are considered a new patient if you have not had an office visit (in-person or telehealth) from our office within the past three years.

If you decide to proceed with Immunotherapy (allergy shots), you verbally agree to have your serum mixed and are responsible for paying any balance regardless of whether you continue your shot regimen.

You are responsible for providing the front and back of all insurance cards at the time of service and updating your insurance as soon as possible if it changes. We will bill up to two insurances as a courtesy. Because insurance plans vary as to allowed amounts, deductibles, coinsurance and copayments, you are responsible for understanding your policy benefits. Also, you acknowledge you are responsible for obtaining preauthorization, if necessary.

Copayments and known balances are due at the time of service, including telehealth visits. If there is a balance remaining, you are responsible to pay the total UPON RECEIPT OF YOUR 1ST STATEMENT from our billing company. In the event the insurance company overpays, a refund will be issued to you or the insurance company. Credits of $25 or less will be held on your account as a credit balance, unless you request a refund. If your contracted insurance has not paid within sixty (60) days of billing you will be required to contact them to find out why the claim has not been paid. You are then required to pay the account balance unless other arrangements have been made and approved by Allergy & Asthma Specialists and our billing company (970-259-8681 MedicalBilling8681@gmail.com).

If you are unable to pay your balance in full upon receipt of your 1st statement, a reasonable MONTHLY payment plan must be set up with our billing company (970-259-8681 MedicalBilling8681@gmail.com). If you have asked for statements to be emailed, please add MedicalBilling8681@gmail.com to your address book so they do not go to your spam folder.

Failure to pay will result in a delinquent account. Interest and billing fees may be charged on delinquent accounts and will be sent to collections. You will be responsible for all collection costs, including attorney and other collection fees.

If sent to collections, you will be required to pay in full before being seen again, or you may be asked to permanently seek care elsewhere in accordance with the guidelines set forth by the Colorado State Board of Medical Examiners.

CANCELLATIONS: Should you need to cancel, or move your appointment, we ask that you do so at least 24 hours in advance. We reserve the right to bill a $100 missed appointment fee.

If applicable, I authorize Allergy & Asthma Specialists and/or its billing agent to release to my insurance or its intermediaries, any information related to the filing of my medical claims, appeals, and authorizations. I authorize the payment of insurance benefits to Allergy & Asthma Specialists.


Medical History

Check all that apply:

Please list medical conditions you are receiving treatment for and include the name of the treating provider:

Please list medications you are presently taking along with the dosages:


Acknowledgment of Receipt of Privacy Practices

Privacy Practices:
● We have an optional text messaging system that requires patients to opt in. You can opt out at any time. This system is not secure so please do not share sensitive information such as social security numbers or credit card numbers.
● We can communicate via e-mail; however, our e-mail is not secure so please do not share sensitive information such as social security numbers or credit card numbers.
● It is the policy of this office to confirm patient appointments and leave voice messages at phone numbers provided by our patient/guardian(s).
● It is the policy of this office to leave phone messages requesting our patients to call us concerning health care issues.
● It is the policy of this office to discuss patient’s health care information with the patient or guardian. If you wish us to discuss patient’s health care information with an alternative individual, please indicate below.

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