Allergen Immunotherapy Consent Form

You will be receiving an extract containing a mixture of allergens to which you are allergic.*
It is very important that you let us know immediately if you have been sick or had any recent medication changes.*
I have discussed allergy injections and the risks with my provider at Arizona Allergy Associates.*
I understand that I must notify the Billing Department immediately of any insurance changes or other circumstances which would affect billing.*
Please check cost for patient prior to making extract.*
We at Arizona Allergy Associates will do everything possible to determine your allergy benefits, but we strongly encourage you to call your insurance company to verify your personal allergen immunotherapy coverage. The codes for allergy shots and allergy extract are as follows: 95115, 95117, 95165, and 95170. Some patients may be candidates for Cluster Therapy and the initial treatments are billed using code 95180. All unpaid balances on allergy extract must be paid in full prior to the renewal of your extract.
Name of Responsible Party*
Patient's Name*
Patient Date of Birth*
Notification*
Name*
Notification Type*

Type name for signature.
Date*
Consent*
This field is for validation purposes and should be left unchanged.

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