Step 1 of 9 11% Email*Welcome to Advanced Allergy and Asthma of Virginia! We are looking forward to your first visit here soon! Please provide us with an email address which will be important in our communication with you Enter Email Confirm Email Cell Number*Hard to live these days without a cell phone. We need this to communicate with you regarding appointments. We never share emails or phone numbers Your pharmacy*Very important! Please tell us location of pharmacy as well. For example: CVS Pikeview, or Walgreens Temie Lee. You can add mail order pharmacy as well such as: Express Scripts, Caremark or OptumPlease list Medications that you are allergic to:PATIENT'S InformationName* First Last Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Land Line Phone if applicableWork Phone #Social Security NumberDate of Birth* Date Format: MM slash DD slash YYYY Marital StatusSingleMarriedDivorcedWidowedPatient Relationship to the Responsible PartySelfSpouseChildOther Referring Physician, Nurse Practitioner or PAName Responsible Party Information (if other than patient)Name of Responsible person* First Last Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth* MM DD YYYY SexFemaleMaleHome Phone #Work Phone #Social Security Number Primary Insurance InformationInsurance Company NamePHONE NUMBER ON INSURANCE CARDSubscriber's (ID#) NumberSubscriber's NamePatient Relationship to SubscriberSelfSpouseChildGroup Number (IF KNOWN)Co-payment AmountSubscriber's Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Secondary Insurance CompanyIF NO SECONDARY INSURANCE- SKIP TO NEXT PAGE Insurance Company NameAddress Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneSubscriber's (ID#) NumberSubscriber's NameSubsciber's date of birthPatient Relationship to SubscriberSelfSpouseChildGroup NameGroup Number Main Reason For VisitNose or Sinus SymptomsCoughing and /or Asthma SymptomsRashes or ItchingFood allergy ReactionsContinuing Care from Previous AllergistSymptom ReviewPlease check if you are experiencing any of the symptoms noted below.Constitutional None Fever Chills Fatigue Weight loss/gain Headache Other Skin None Rashes Persistent Itching Ears, Eyes, Nose, and Throat None Nasal/sinus congestion Ear Pain or drainage Hoarseness itchy/red eyes Sore throat; raspy voice Swollen glands Other Neurological None Headaches Vertigo Fainting Spells Other Respiratory None Shortness of breath Wheezing or Spasmodic Coughing Snoring Sleep Apnea Other Symptom Review (Continued)Please check if you are experiencing any of these symptoms.Gatrointestinal None Heartburn (reflux) Nausea Vomiting Abdominal pain Diarrhea Musculoskeletal None TMJ ( jaw joint problems) Joint pain Back pain Other Psychologic None Anxiety/panic disorder Depression ADHD Other Cardiovascular None Chest Pain Palpitations Other Endocrine Diabetes Thyroid problems Other Hematologic None Blood clotting problems ( i.e hemophylia) Other Family Health HistoryInclude which relative and type of illness/disease (for over age 14 only.)Patient's OccupationTobacco Use:YesNoFormer Smoker ( stopped more than a year ago)Vape?Alcohol UseYes almost dailySocial DrinkerNever or RarelyCurrent Medications & DosageEspecially allergy or asthma medications including inhalers Past Surgeries/Hospitalizatons/Severe Illnesses (and approx. year)Medical AllergiesOur Financial PolicyPlease review and sign below Thank you for choosing Advanced Allergy and Asthma of Virginia as your healthcare provider. We are committed to your assessment and treatment being a successful experience. The following is a statement of our Financial Policy which we require you to read and sign prior to any encounter. All patients must complete this information before being seen by the Doctor. In the event that there is no available insurance to cover your visit and services, payment is due in full at the time of service. WE ACCEPT CASH, CHECK OR CREDIT CARDS (MasterCard, Visa and Discover Card) Regarding Insurance We may accept assignment of insurance benefits if we are a contracting provider with your insurance company. However, we do require that all co-payments be made at the time of service. The balance is YOUR responsibility whether your insurance company pays or not. We cannot bill your insurance company unless you give us your insurance information and an original insurance card at your initial visit and with subsequent visits as requested, to copy and keep on file. Your insurance policy is a contract between you and your insurance company. We are not a party to that contract. Please be aware that some, and perhaps all, of the services provided may be non-covered services and/or not considered reasonable and necessary under the Medicare Program and/or other medical insurance. You agree to be responsible for these balances. In the event your insurance requires you to obtain a PREAUTHORIZATION referral prior to services you agree and acknowledge that you are responsible for coordinating and obtaining such documents. Adult and Minor Patients Adult patients are responsible for full payment at the time of service. The adult accompanying a minor and/or the parents (or guardians of the minor) are responsible for full payment. For unaccompanied minors , non-emergency treatment will be denied unless charges have been pre-authorized to an approved credit card, MasterCard, Visa or Discover Card, (which may be kept on file), or payment by cash or check at the time of service has been verified. Returned Checks There will be a $50.00 return check fee on all returned checks. You agree to be responsible for these fees. In the event that a check is returned for insufficient funds, we reserve the right to call your bank to verify funds for any future checks that are presented for payment on your account. Collection Fees In the event we are placed in the unfortunate position that we must turn your delinquent account over to a Collection Agency and/or Collection Attorney you will be responsible for all collections costs including a recovery fee of 38% of the balance due, as well as any and all court costs and attorney fees that may be incurred. Missed Appointments Unless cancelled, at least 24 hours in advance of your scheduled appointment, our policy is to charge $35.00 for all missed appointments. Please assist us in our service to you by keeping scheduled appointments. FEES FOR LETTERS AND FORMS AND RX AUTH ETC. Your Physician and Staff will be happy to fill out any necessary forms that you may need. There will be a $15 charge for school forms and work forms unless these are brought with the patient at an official office visitAdditionally, there will be a $25 charge for any prior authorization requested by the patient or patient's family for any OVER THE COUNTER medicine. These costs are considered non-covered by insurance companies, thus, payment of this fee wii be due at the time of request. Telephone and Fax Policies Our policy is to avoid faxing medical records to anyone other than medical providers. In the event of an emergency situation, consent is made to share information with other providers for continuity of care purposes. Answering Machines and Voice Mail In the event that we need to get in touch with you regarding test results, confirmation of appointments or discussion of treatment, consent is made to leave a message on your electronic machine or voicemail service requesting you to contact our office. No specific information regarding test results or diagnoses will be left as messages via an electronic machine or service. Thank you for understanding our Financial Policies. Please let us know if you have any questions or concerns. I HAVE READ THE FINANCIAL POLICY ABOVE AND I UNDERSTAND AND AGREE TO ALL PROVISIONS OF THIS POLICY.*Type your full name to digitally sign.Relationship to Patient Written Acknowledgement of Privacy and Disclosure PracticesOur Notice of Privacy Practices (NPP) provides information about how we may use and disclose Personal Health Information (PHI) about you. As provided in our notice, the terms of our notice may change. If a change in our notice is necessary you will be provided a revised copy. By signing below you are acknowledging that you have been offered and/or received our Notice of Privacy Practices (NPP). I have had the opportunity to read the Notice of Privacy Practices (NPP) of Advanced Allergy and Asthma of Virginia. I understand that I may ask questions of the Staff of Advanced Allergy and Asthma of Virginia if I do not understand any information contained in the Notice of Privacy Practices. I HAVE READ THE WRITTEN ACKNOWLEDGMENT OF PRIVACY AND DISCLOSURE PRACTICES ABOVE AND AGREE*Type your Full Name to digitally sign.Relationship to Patient* Permission to Disclose Private Health InformationBy signing on this page, I give permission to the person(s) listed below to receive my Private Health Information. I understand that this form is legally binding and that I may revoke my authorization at any time by submitting in writing, my request for changes, additions or termination of the information designated below. List each individual's full name, who you give permission to receive your Private Health Information:Write any comments to the right of the name, if necessary.I GIVE PERMISSION TO THE PERSON(S) LISTED ABOVE TO RECEIVE MY PRIVATE HEALTH INFORMATION, AND I UNDERSTAND THIS FORM IS LEGALLY BINDING.*Type your Full Name above to digitally sign.Relationship to PatientCommentsThis field is for validation purposes and should be left unchanged. 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