New Patient Registration

IDENTIFICATION: It is your responsibility to notify our office of any patient information changes (i.e. address, name, insurance information, credit card on file, etc.) as soon as possible.

PROOF OF INSURANCE: Patients are responsible to provide the correct insurance information at each visit. If current information is not obtained at the time of service, the balance will become the patient’s responsibility. If information is not received in a timely fashion or is incorrect, we may be unable to resubmit charges to the new insurance due to timely filing limitations. In this event, the balance will remain the patient’s responsibility.

Your insurance is a contract between you and your insurance company. It is your responsibility to know your insurance benefits, including but not limited to, deductible, co-payment amounts, laboratory services, radiology facilities and hospitals associated with your plan. If you are covered by an insurance plan that AAA in not contracted with or participates with, or you have no insurance coverage, our charge for your care or the care of your dependents will be due at the time of service.

We are contracted with most insurance plans and will file claims and process these as required by these contracts. We will file a claim for you as a courtesy if we are not contracted with your insurance carrier/plan. We will not become involved in disputes between you and your insurance carrier. This includes, but not limited to, deductibles, co-payments, non-covered charges and “usual and customary” charges. We will supply information as necessary to you and/or your insurance company. You are ultimately responsible for the timely payment of your account. If your insurance company does not pay us within a reasonable time, we may look to you for a payment for services rendered. All plans are not the same and they do not cover the same services. In the event your insurance company determines a service provided was “not covered”, you will be responsible for the complete charge. We will provide an estimate of charges upon request.

Patients will be requested to maintain a valid credit card on file for any balances that are not paid by your insurance. You will be requested to sign a credit card authorization form, which permits us to charge your credit card in the event you have any charges that are not covered by your insurance, charges that fall under the co-payment or deducible portion of your plan, or administrative fees that are assessed by AAA such as no-show fees. We do not accept Cash. Payments are accepted with Visa, MasterCard, American Express, Discover, Apple Pay, Google Pay, Samsung Pay, personal check, Cashier’s check, or Money Order with a valid ID only.

REFERRAL: If you need an insurance referral from a primary care physician, make sure the referral is in our office BEFORE YOUR SCHEDULED APPOINTMENT. Referral Fax: 480-839-1874. If we do not have this information by the date of your visit, your appointment may need to be rescheduled.

INSURED PATIENTS: All copays must be paid at time of service. If you are unable to pay your copay at time of service, your appointment may need to be rescheduled.

Any questions regarding bills must be directed to the billing department. Any information given from sources outside of the billing department by other staff members (front office, physicians, clinical staff, etc.) regarding the billing of services will not be honored.

SELF PAY PATIENTS: Arizona Allergy Associates requires full payment at time of service unless prior arrangements have been made with our billing department. A discount is offered if paid in full at time of visit.

NON-COVERED SERVICES: Patients are responsible for services not covered by their insurance carrier.

OUTSTANDING BALANCES/COLLECTIONS: Patient balances need to be paid in full within 60 days of their first statement. Balances unpaid after 90 days are considered delinquent and subject to debt collection. If you are unable to remit the balance within the 90 days please call our billing department to discuss payment plan options. Failure to do so will result in your account being turned over to a third party collection agency, and a fee of 40% of the delinquent amount will be added to your balance. If an account balance is outstanding it must be paid in full prior to any future services.

CANCELLATION/NO SHOW POLICY: We require a 24 hour notice if you need to cancel or reschedule your appointment. If we do not receive notification within this time frame, we will assess a “no show” fee of $75.
Note: This assessment will not be charged to your insurance company and you will be solely responsible for payment.
If discharged from our practice due to multiple no shows or any other inappropriate behavior, you will be notified in writing via Certified Mail.

BALANCES ON IMMUNOTHERAPY: Any unpaid balances including allergy extract must be paid in full prior to the renewal of your extract for the next year.

MEDICAL RECORDS/FORMS: We reserve the right to charge for copies of your patient records. You may request a copy of records annually at no cost. There is no cost to copy records for other physician offices. A charge of $25 may be assessed for any forms that need to be filled out by our providers prior to the paperwork being completed.

• I hereby assign my insurance benefits to be paid directly to the physicians or, if my current policy prohibits direct payment to the doctor, I instruct and direct my insurance company to make the check payable to Arizona Allergy Associates and me.

• I authorize the physician to deposit checks received on the patient’s account when made out to the patient.

• I authorize the physician to release any information required to process claims or required in the course of my exam and treatment.

• I hereby agree to pay my account as services are provided. If for any reason a balance is owed on my account, I agree to pay promptly upon receipt of the monthly statement.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Uses and Disclosures

Treatment: Your health information may be used by staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example, results of laboratory tests and procedures will be available in your medical record to all health professionals who may provide treatment or who may be consulted by staff members.

Payment: Your health information may be used to seek payment from your health plan, from other sources of coverage such as an automobile insurer, or from credit card companies that you may use to pay for services. For example, your health plan may request and receive information on dates of service, the services provided, and the medical condition being treated.

Health care operations: Your health information may be used as necessary to support the day-to-day activities and management of Arizona Allergy Associates. For example, information on the services you received may be used to support budgeting and financial reporting, and activities to evaluate and promote quality.

Law enforcement: Your health information may be disclosed to law enforcement agencies to support government audits and inspections, to facilitate law-enforcement investigations, and to comply with government mandated reporting.

Public health reporting: Your health information may be disclosed to public health agencies as required by law. For example, we are required to report certain communicable diseases to the state’s public health department.

Other uses and disclosures require your authorization: Disclosure of your health information or its use for any purposes other than those listed above requires your specific written authorization. If you change your mind after authorizing a use or disclosure of your information, you may submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified us of your decision to revoke your authorization. Without your authorization, we are expressly prohibited to use or disclose your protected health information for marketing purposes when financial remuneration is involved. We may not sell your protected health information without your authorization. We may not use or disclose most psychotherapy notes contained in your protected health information. We will not use or disclose any of your protected health information that contains genetic information that will be used for underwriting purposes.

Additional Uses of Information

Appointment reminders: Your health information will be used by our staff to send you appointment reminders.

Information about treatments: Your health information may be used to send you information on the treatment and management of your medical condition that you may find interesting. We may also send you information describing other health-related products and services that we believe may interest you.

Individual Rights

You have certain rights under the federal privacy standards. These include:

• The right to request restrictions on the use and disclosure of your protected health information

• The right to receive confidential communications concerning your medical condition and treatment

• The right to inspect and copy your protected health information

• The right to amend or submit corrections to your protected health information

• The right to receive an accounting of how and to whom your protected health information has been disclosed

• The right to receive a printed copy of this notice

Arizona Allergy Associates’ Duties

We are required by law to maintain the privacy of your protected health information and to provide you with this notice of privacy practices. We also are required to abide by the privacy policies and practices outlined in this notice. In the event of a breach of unsecured protected health information, if your information has been compromised it is our duty to notify you.

Right to Revise Privacy Practices

As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in federal and state laws and regulations. Upon request, we will provide you with the most recently revised notice on any office visit.

The revised policies and practices will be applied to all protected health information we maintain.

Requests to Inspect Protected Health Information

You may generally inspect or copy the protected health information that we maintain. As permitted by federal regulation, we require that requests to inspect or copy protected health information be submitted in writing. You may obtain a form to request access to your records by contacting a Front Office Coordinator or the HIPAA Privacy and Security Officer. Your request will be reviewed and will generally be approved unless there are legal or medical reasons to deny the request.

Arizona Allergy Associates has a “No Photo, Video or Recording” Policy

Photography, video, or audio recording of any kind is not permitted within, nor outside the premises of any Arizona Allergy Associates facility. This policy is in place to protect patient privacy, enhance confidentiality, and maintain security. With your safety and the safety of Clinic staff in mind we ask that you refrain from videotaping or taking photos, videos, or recordings of any kind with your camera, cell phone, smart phone, tablet, or any other device without prior consent and supervision of the site Manager.

Our staff, doctors and other providers are not permitted to give you permission to take photos or recordings within Clinic facilities and are authorized to enforce this policy. For additional information, please speak to an Arizona Allergy Associate Clinic Manager on-site.

If you would like to obtain copies, electronic images, or other records of your medical visits, please sign a medical record release.

Complaints

If you would like to submit a comment or complaint about our privacy practices, you can do so by sending a letter outlining your concerns to:

HIPAA Privacy and Security Officer
Arizona Allergy Associates
705 South Dobson Road
Chandler, AZ 85224

If you believe that your privacy rights have been violated, you should call the matter to our attention by sending a letter describing the cause of your concern to the same address. You will not be penalized or otherwise retaliated against for filing a complaint.

Effective Date: This notice is effective on or after June 1, 2017

Arizona Allergy Associates reserves the right to modify the privacy practices outlined in the notice.

Any testing that may be required will be discussed with the provider at the time of your appointment. We may be able to do skin testing, if indicated, but our testing protocol requires that patients not take any antihistamines for five (5) days prior to skin testing; however, some medications may require additional avoidance. If you are taking antihistamines prescribed by your physician or if you have significant skin irritation or hives, please do not discontinue the antihistamines. Any skin testing that is required will be scheduled after you have seen a provider here.

• Acrivastine/Bromfed/Dimetapp Cold and Allergy
  Brompheniramine

  • Allegra Fexofenadine

  • Benadryl Diphenhydramine

  • Kronofed

  • Pepcid Famotidine

  • Tavist/Dayhist Clemastine

  • Xyzal Levocetirizine

  • Any medication with “sinus”, “allergy”

• Advil PM

  • Antivert Meclizine

  • Chlor-Trimeton/Deconamine/Extendryl/Hycomine Compound Chlorpheniramine

  • Nyquil/ZzzQuil

  • Periactin Cyproheptadine

  • Tussionex

  • Zaditor/Alaway Ketotifen

  • OTC cough & cold medications

• Alavert/Claritin Loratadine

  • Astelin/Astepro Azelastine

  • Clarinex Desloratadine

  • Pataday/Patanol, Pazeo Olopatadine

  • Pyrilamine

  • Tylenol with one or more of the following added to the name: Allergy, Cold, Flu, PM

  • Zantac Ranitidine

  • OTC sleep medications

• Alka Seltzer Plus Cold

  • Atarax/Vistaril Hydroxyzine

  • Doxepin

  • Phenergan Promethazine

  • Tagamet Cimetidine

  • Unisom

  • Zyrtec Cetirizine

  • Any medication with “hist”
    

Q: How does the automatic billing process work?
A: Your credit card will be captured today and stored securely. After your insurance carrier responds and provides us your remaining balance due we may charge the patient responsibility to your credit card. Your credit card on file will only be charged when you have a balance owing on your account or for a non-covered service.

Q: How will I know how much you are going to charge me?
A: You will receive an explanation of benefits from your insurance carrier that explains exactly, according to your health insurance coverage and benefits, how much of your healthcare bill is your responsibility and how much the insurance paid along with any contractual adjustments.

Q: What if I need to dispute my bill?
A: We will always work with you to resolve any issues and will refund you if we have made a billing error. We will only charge you the amount that we are instructed by your insurance carrier to collect from you in the same way that we normally determine how much to send you a statement for in the mail. If you disagree with how your insurance carrier processed the claim, you will need to contact their customer service department directly.

Q: Will I receive a statement or receipt for the charges automatically billed to my card?
A: Not automatically. Your insurance carrier EOB and your credit card statement will be your receipt. You can at any time contact us to have an account itemization emailed to you.

Q: What is a deductible?
A: An annual deductible is the dollar amount you must pay out of your own pocket during your plan year for medical expenses before your insurance begins to pay. For example, if the policy has a $1,000 deductible, you must pay the first $1,000 of medical expenses before your insurance will begin to pay. Your insurance company must receive a claim to process in order to apply balances towards your deductible. Even if you have a high deductible plan, we encourage you to have us submit the claim to your insurance so you receive a contractual adjustment and the services can be applied towards your deductible.

Q: Is my credit card secure?
A: Yes, we do not store your sensitive credit card information in our office. Keeping your card on file, offsite, in an encrypted payment gateway actually enhances security because it reduces exposure at each visit.