SUGAR LAND ALLERGY, ASTHMA & IMMUNOLOGY CENTER, P.A.

4820 Sweetwater Blvd. Sugar Land, TX 77479
281-494-4600 (Phone) 281-494-4605 (Fax)
David Amran, M.D., F.A.A.A.A.I.

**For skin testing stop antihistamines 5-7 days prior to appointment. Continue all other medications including your asthma medicines. Please do not wear perfumes or colognes to the office. (This information needs to be updated every 3 months or as needed due to any changes.) Option: Print and answer all questions and present to the front desk upon arrival for your appointment.

Patient's Information

Primary Care Physician:

Primary Care Physician Phone Number:

Pharmacy Name:

Pharmacy Number:

Referred By:

Name:(Required)

First Middle Last

Date of Birth:(Required)

SSN:

Sex:(Required)

Male

Female

Driver's License#:(Required)

Race:

American Indian/Alaska Native

Asian

Black/African American

National Hawaiian/Pacific Islander

White

Declined

Other

Unknown

Address:(Required)

Phone Number (Cell/Home):(Required)

Email:(Required)

Marital Status:

S

M

W

D

Student?

Yes

No

Employer:(Required)

Occupation:

Employer Address:

Work Phone:

Reason for Visit (Symptoms):(Required)

Emergency Contact

Name:

Relationship:

Phone Number 1:

or Phone Number 2:

INSURANCE

*If there is two active insurances, a primary and ,secondary plan need to be established and both insurances need to be aware of each other; call both plans and state you want to update Coordination of Benefits.
Primary Insurance: (HMO plans need to have a referral from your PCP before being seen in our office.)

Name of Insurance:

Phone Number:(Required)

Policy/Subscriber ID:(Required)

Group Number:(Required)

Referral Number:

Relationship to Patient:

Guarantor Name:(Required)

First Middle Last

Date of Birth:(Required)

SSN:

Sex:

Male

Female

Driver's License#:

Address:

Phone Number (Cell/Home):

Email:

Employer:

Occupation:

Employer Address:

Work Phone:

Secondary Insurance:(HMO plans need to have a referral from your PCP before being seen in our office.)

Name of Insurance:

Phone Number:

Policy/Subscriber ID:

Group Number:

Referral Number:

Relationship to Patient:

Guarantor Name:

First Middle Last

Date of Birth:

SSN:

Sex:

Male

Female

Driver's License#:

Address:

Phone Number (Cell/Home):

Email:

Employer:

Occupation:

Employer Address:

Work Phone:

If my insurance plan denies payment due to coverage changes, wrong benefits given by ins., member ID changes, cobra payment, current referral or I (patient/guardian) failing to provide our office with current coverage information for services rendered. I agree to be personally responsible for payment of these services.

Patient/Guardian Signature:(Required)

Date:(Required)

NO INSURANCE (SELF PAY)

If you do not have insurance, payment is due in full at time of service.

Patient/Guardian Signature:

Date:

Sugar Land Allergy, Asthma & Immunology Center
(PLEASE READ ALL CAREFULLY & SIGN BELOW)

FINANCIAL POLICY

We appreciate the confidence you have expressed in selecting our Physician/ Physician Assistant's as your Allergist. If you have any questions about our services, fees, or other aspects of your care please feel free to discuss them with our Front Desk/Billing Personnel.
Your clear understanding of our Financial Policy is important to our professional relationship.

Payment in full for services rendered is required at the time of service which include:
(Copays/Deductibles/Coinsurance/OOP/Non-Covered Services)

Patients without insurance or patients who are not covered by one of our contracted insurance plans.
Patients who do not provide us with current contracted insurance information.
Patients who are required to have prior referral/authorization from their insurance carrier or Primary Care Physician, who have not obtained such authorization; (in which you should contact your PCP office).
As well as any services rendered in office which is not covered by the insurance and patient chooses to continue with treatment; patient will be considered Self Pay.
- As a courtesy our front office staff will call your insurance company to verify benefits using the provider services phone number given on your insurance card.
  THIS VERIFICATION IS NOT A GUARANTEE OF PAYMENT (OUR OFFICE WILL NOT BE RESPONSIBLE FOR INCORRECT BENEFITS GIVEN TO US BY YOUR INSURANCE OR FOR CHANGES IN COVERAGE), IT IS YOUR (Patient/Guarantor/Guardian) RESPONSIBILITY TO KNOW AND UNDERSTAND YOUR OWN INSURANCE BENEFITS, COVERAGE, AND REFERRAL/AUTHORIZATIONS REQUIREMENTS.
- Our billing staff will file your claims with your Primary and Secondary insurance only (as long as your Coordination of Benefits is updated with your Primary & Secondary Plans). It is Mandatory to provide our office with all medical coverage, including insurance through your employer and/or government insurance.

ACKNOWLEDGEMENT AND AUTHORITY

I consent to treatment as necessary or desirable to the care of the patient first name below, including but not restricted to whatever drugs, medicine, conduct of laboratory, x-ray, or other studies that may be used by the physician, nurse, or qualified designate. I authorize Sugar Land Allergy to release information as required to my PCP, my insurance, or third party payor for the purpose of determining benefits. l also authorize Sugar Land Allergy to bill my insurance or third party payor and receive payment from them for services rendered. This authorization shall remain valid until such time as I revoke it in writing. A photocopy or facsimile copy of this authorization shall be deemed as valid as the original.

NOTICE OF BALANCE PAYMENT

Please know you will be made aware of any outstanding balance on your account through statements in mail. You will be required to make a payment or payment arrangements on any outstanding balance you may have accrued prior to scheduling a follow-up appointment with us. However, after 90 days of nonpayment or a total of 3 mailed statements your case will be sent to our collection agency.

Print Patient name:

Patient/Guardian Signature:(Required)

Date:(Required)

NO SHOW POLICY

We make every effort to provide prompt medical care to all of our patients. If you are unable to keep a scheduled appointment, please let us know 24 hours in advance. A no show fee may generate a $25.00 fee per incident.
In the event that you have a special circumstance regarding your missed appointment, please contact our office. We understand that there may be issues beyond your control and want to be understanding of special circumstances.

LATE POLICY

Sugar Land Allergy, Asthma, & Immunology Center, P.A is diligently working to provide excellent medical care to every patient in a timely manner.
Please contact our office if you will be late for your appointment. There is a 15 minute grace period as long as we have been made aware, anything later we will have to reschedule to our next available appointment.

ADMINISTRATIVE PAPERWORK FEE

Sugar Land Allergy, Asthma, & Immunology Center, P.A will charge $25.00 administrative fee for any forms, paperwork that we are asked to complete or write for you. The fee is payable at the time the forms are submitted for completion. Forms requiring the fee would include, but not limited to FMLA paperwork, school forms, detailed release to work forms, medication assistance forms, etc.
*For any school forms required to be completed if the patient has not been seen in the office within 3 months the patient would need to be scheduled and be seen by one of our providers before any school forms are completed. Office visit charges would be in addition to the $25.00 administrative fee.
Please allow 7-10 business days for all forms to be completed; completed forms can be picked up from the front desk or can be faxed (if requested and not over 25 pages).

MEDICAL RECORDS

Sugar Land Allergy, Asthma, & Immunology Center, P.A will provide your records to you once you have completed the appropriate medical records request form.You can contact our office and we can mail or fax the form to you.
Fee for records, $25.00 for the first 25 pages and 50 cents for every page after.
Your request will be processed and fulfilled within 15 business days.

RETURNED CHECKS NSF

There is a $35.00 charge for any returned checks in addition to the insufficient funds amount.

Patient Name:

Patient/Guardian Signature:(Required)

Date:(Required)

Patient Name:

MESSAGE AUTHORIZATION

Sugar Land Allergy, Asthma, and Immunology Center, P.A.

Considers patient confidentiality to be of utmost important and concern. In an effort to ensure your privacy is protected, please read and sign the following concern.

AUTHORIZATION

(Initial) I, authorize Dr. Amran/ office staff to leave a message on my home answering machine pertaining to my medical care such as appointments, results, etc. (Required)

(Initial) I, authorize Dr. Amran/ office staff to leave a message on my work answering machine pertaining to my medical care such as appointments, results, etc. (Required)

(Initial) I, authorize Dr. Amran/ office staff to discuss my medical care with (please list all names that apply) (Required):

Names

I understand that this authorization will remain in effect until such time that I submit, in writing, revocation of my authorization. I understand that by giving my consent, information about my personal health care could be made available to members of my family and/or others who have access to my telephone messaging system.

Signed:(Required)

Date:(Required)

NO AUTHORIZATION

I do not authorize any messages related to my healthcare to be left on my home answering machine.
I do not authorize any messages related to my healthcare to be left on my work answering machine.

Signed:

Date:

AUTHORIZATION REVOKED

Message authorization revoked on (date):

Initials of individual receiving written revocation:

ACKNOWLEDGEMENT

I, (patient), acknowledge that I have seen a copy of Sugar Land Allergy, Asthma & Immunology Center
(the practice's)
Notice Regarding Privacy of Personal Health Information.

Patient's Signature:(Required)

Date:(Required)

Patient/Guardian Signature:(Required)

Date:(Required)

If you would like an original copy of the Privacy Information please ask the front desk.

Parking Notice-Effective April 1, 2010
TO PREVENT TOWING OF YOUR VEHICLE!

PLEASE SIGN IN WITH OUR FRONT DESK DURING BUSINESS HOURS IF YOU ARE PARKED IN THE FRONT OR SIDE OF OUR BUILDING AND ARE PLANINGS TO WALK OVER TO ANOTHER PLACE OF BUSINESS PRIOR TO YOUR TREATMENT IN OUR OFFICE OR AFTER YOUR TREATMENT AT SUGAR LAND ALLERGY, ASTHMA & IMMUNOLOGY CENTER, P.A.
ALL UNAUTHORIZED VEHICLES PARKED IN OUR RESERVED SPACES BEFORE OR AFTER SUGAR LAND ALLERGY, ASTHMA & IMMUNOLOGY CENTER, P.A. BUSINESS HOURS. WILL BE TOWED.
OUR RESERVED PARKING IS FOR OUR PATIENTS/VISITORS THAT ARE HAVING TREATMENT IN OUR OFFICE ON THAT DAY
TOWING IS ENFORCED AT ALL TIMES

This is an acknowledgment that you have been informed and understand the above towing rules for S.L.A.

Patient Name:(Required)

Date:(Required)

Patient/Guardian Signature:(Required)

Date:(Required)

ADULT PATIENT QUESTIONNAIRE

Name of Surgeon/Provider

Surgery or Precedure

Date of Procedure

Name of Surgeon/Provider

Surgery or Precedure

Date of Procedure

Name of Surgeon/Provider

Surgery or Precedure

Date of Procedure

Name of Surgeon/Provider

Surgery or Precedure

Date of Procedure

Name of Surgeon/Provider

Medications Taken Regularly

Include all oral, inhaled, intravenous and subcutaneours medications as well as all herbal medications, supplements, vitamins and over-the-counter medications. If needed, please provide a separate list.

Medication Name 1

Dose

Route (Oral, Inhale)

How Often?

Medication Name 2

Dose

Route (Oral, Inhale)

How Often?

Medication Name 3

Dose

Route (Oral, Inhale)

How Often?

Medication Name 4

Dose

Route (Oral, Inhale)

How Often?

Medication Name 5

Dose

Route (Oral, Inhale)

How Often?

Medication Name 6

Dose

Route (Oral, Inhale)

How Often?

Medication Name 7

Dose

Route (Oral, Inhale)

How Often?

Medication Name 8

Dose

Route (Oral, Inhale)

How Often?

Medication Name 9

Dose

Route (Oral, Inhale)

How Often?

Medication Name 10

Dose

Route (Oral, Inhale)

How Often?

Medication Name 11

Dose

Route (Oral, Inhale)

How Often?

Medication Name 12

Dose

Route (Oral, Inhale)

How Often?

Medication Name 13

Dose

Route (Oral, Inhale)

How Often?

Medication Name 14

Dose

Route (Oral, Inhale)

How Often?