PAYMENT POLICY – Please read carefully, sign and bring to your first appointment.

TO ALL OUR PATIENTS

The average evaluation consists of an initial 1-2 hour consultation plus 2 or 3 shorter visits for skin

testing and laboratory study. Although the final fee is determined on the basis of the number of visits,

skin tests & laboratory tests required to reach a precise diagnosis, the total charge may exceed $800.

Some patients will require desensitization therapy. In those cases, there will be an additional charge

for the treatment material and the injections.

Patients under the age of 18 MUST HAVE A PARENT PRESENT FOR ALL VISITS.

REGARDING INSURANCE

Patients who carry health insurance should remember that the professional services are rendered

and charged to the patient and NOT THE INSURANCE COMPANY.

At present, we participate with the following major insurance companies:

AETNA, EXCELLUS BC/BS, CDPHP, FIDELIS, MEDICARE, MVP, PHCS, POMCO, RMSCO,

TOTAL CARE & UNITED HEALTH CARE (except CHP/Medicaid) as well as several other smaller

entities. If you do not see your healthcare carrier mentioned, please call the company’s. Provider

Services unit to inquire about our participation. ALL CO-PAYMENTS ARE DUE AT TIME OF

SERVICE. It is the patient’s responsibility to obtain referrals if necessary. Contact your insurance

company for details.

WE DO NOT PARTICPATE IN STRAIGHT MEDICAID.

NON-PARTICIPATING INSURANCE COMPANIES (such as Empire).

As a courtesy, we will submit bills to your insurance company. You will receive a monthly statement

for the balance due. This office cannot accept responsibility for collecting your insurance claims or

for negotiating any disputes. You are responsible for checking on the coverage your policy provided

and adhering to our payment policy. If you have any questions, we will be happy to assist you.

PLEASE CALL US IF YOU FIND YOU CANNOT ADHERE TO THE PAYMENT POLICY.

We can discuss further arrangements. (OTHERWISE, IF 2 MONTHS PASS WITH NO PAYMENT,

FINANCE CHARGES WILL AUTOMATICALLY BEGIN).

I hereby assign, transfer and set over to ALLERGY ASTHMA RHEUMATOLOGY ASSOCIATES

all of my rights, title and interest to any medical reimbursement benefits under my insurance policy.

I authorize the release of any medical information needed to determine these benefits.

The authorization shall remain valid until written notice is given by me revoking said authorization.

I have read the above PAYMENT POLICY and I agree to its contents.

_____________________________________ __________________________

Signed by Patient or Parent if Minor Date