Thank you for your interest in our practice.

To ensure we are best suited to serve you, we have developed a comprehensive, detailed intake form.

Given the length of this form, we strongly recommend that you complete it using your desktop/laptop computer.

We look forward to helping you with your healthcare needs.
Patient Information
Sex     

Emergency Contact
Employment Information

Patient or Parent/Guardian of a Minor

Spouse/Significant Other OR the second parent/guardian of a minor

Physician Information

PCP

Specialist

Health Insurance
How did you hear about Colorado Allergy and Asthma Centers? (check one)
Were you referred by a physician or other provider?
Previous Allergy Evaluations
Previous allergy evaluation?
Skin testing?
Blood testing?
Were you allergic?
Allergist name:
Allergist state:
Previous allergy injections?
Insect Sting Reactions
Drug Allergies/Intolerances:
Food Allergies/Intolerances:
Latex or Rubber Allergies/Intolerances:
Past Medical History
Flu vaccine
Pneumonia vaccine
T.B. test
Birth history (if patient is a child)
Hospitalizations:
Surgeries:
Serious Injuries:
Other Medical Problems:
All Current Medications not already listed
Include Over-The-Counter and Supplements.
Family History
FAMILY HISTORY
Do any close family members have the following? Check the appropriate box below: (even if mild or outgrown)
Immune problems:
Cystic fibrosis:
Emphysema:
Social History
Have you ever smoked?
Alcoholic beverages?
Marijuana or other "recreational" drugs?
Review of Systems
General
Eyes

Mouth/Throat

Heart
Gastrointestinal

Genitourinary

Musculoskeletal

Endocrine

Neurologic

Blood / Lymphatic

Other symptoms or medical problems (list)
 
Environmental History
How long has patient lived in Colorado?
What other states/countries has patient lived in?
Primary Home
Type of home?
Age of home?
Construction
Basement:
Heating and Cooling
Heat:
Cooling system:
Central filter type:
Room air filter:
Air ducts cleaned:
Mold and Moisture
Humidifier:
Water leak(s):
Cleaning
Frequency of dusting:
Frequency of vacuuming:
Patient's Bedroom
Flooring:
Mattress:
Pillow:
Pets
Do you have pets?
Smokers (at your home)
Do you have a second home?
Other Environments
Daycare
Relatives' Homes
School/Work
Hobbies/Interests
Hobbies/Interests
Occupation / School / Daycare
Type of work / school / daycare:
Kinds of materials exposed to at work / school:
Upper Respiratory Tract (Nose, Sinus, Ear, and Eye) Problems
Do you have Upper Respiratory Tract (Nose, Sinus, Ear, and Eye) Problems?
Lower Respiratory Tract (Chest, Lung) Problems
Do you have Lower Respiratory Tract (Chest, Lung) Problems?
Skin Problems
Do you have Skin Problems?

Release of Information

I authorize the release of any information necessary to process claims. I request payment of benefits to Colorado Allergy and Asthma Centers. I understand I am financially responsible for charges not covered by this authorization.

I understand and agree if care at Colorado Allergy and Asthma Centers requires Primary Care Physician referral, it is my responsibility to see that the referral is current prior to receiving care at Colorado Allergy and Asthma Centers. If no referral is present in advance, I agree to pay for charges.

SIGN WITH FINGER (PHONE/TABLET) OR WITH COMPUTER MOUSE.

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Consent for care of minors

Because my son/daughter is a minor (less than eighteen (18) years of age) and primarily supported by parent or guardian, I understand and agree that he/she may be evaluated and/or treated by Colorado Allergy and Asthma Centers’ staff if I am not present to give consent. This may include, but necessarily limited to, physical exams, skin tests, laboratory test, allergy injections and the prescription of medications in my absence. This agreement will be in effect until revoked by me in writing.

SIGN WITH FINGER (PHONE/TABLET) OR WITH COMPUTER MOUSE.

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HIPAA Privacy Notice – Patient Acknowledgement “Health Insurance Portability and Accountability Act

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.

The Federal Government has required that your medical records remain private, confidential, and unavailable to anyone without your expressed written consent. Our medical record of your care remains the physical property of Colorado Allergy and Asthma Centers, P.C. The State of Colorado supports this law. Forms are used for you to authorize, in writing, the release of a copy of your specific medical records to another entity such as; physician, medical practice, or to an insurance company for treatment, payment, and operations of CAAC.

Health Care Operations

There remain certain operational activities, where, in the process of delivering medical care to our patients, specific disclosure of information becomes necessary and will be conducted by medical and administrative professionals within this practice, without expressed written permission of each and every specific occurrence by you. Some examples include:
 
  • Requesting Photo ID at your visit
  • Taking and saving a photograph of the patient for the chart to be used for identification and medical treatment
  • Communicating with your pharmacy, insurance carrier, primary care provider, and other professionals involved in the patient’s healthcare (such as schools, day care or college heath centers)
  • Handling of the mail, newsletters, claims, bills, referrals
  • Requesting that the office / reception staff call, text, or email you to schedule an appointment, acquire a referral, or to inform you about medications that may have to be held for testing
  • Medical staff leaving reasonable and limited messages informing you of potential treatment options such as lab or x-ray results
  • Inform you of health-related benefits or services that may be of interest to you
  • Verbal or written correspondence with insurance companies; yours and ours
  • Discussing an opportunity to enroll you in ongoing Asthma Allergy Research; and/ or continuation in research studies/ clinical trials
  • Routine inter-office communication between professional staff of this specialty practice to effectively manage your medical care
You may restrict disclosure of any part of your Private Medical Information from within this practice to any outside source or recipient, where not allowed by law: Federal, State or by Court Order. Please note that any unsecure electronic communication initiated by the patient/family is done so at their own risk


Your Rights under the Law:

You have the right to receive a notice about our privacy policy
The right to inspect your protected health information (PHI) with a provider in a private environment
The right to request a copy of PHI and to have returned to you in 30 days, unless notified in writing of 60-day return The right to request a restriction on uses and disclosures of your protected health information
The right to request to receive confidential communications from the practice by alternative means or at an alternative location
The right to request an amendment of your protected health information
The right to request an accounting of disclosures of Protected Health Information (PHI) The right to revoke or limit authorization
The right to be notified of a breach of your PHI

Please list by name and relation the person(s) that may receive messages or talk to us regarding patient’s medical care.


Practice Duties
It is our responsibility to guard and maintain information about you and your health in a very private manner. This information will be disclosed within the practice on a “needs to know” basis, and then kept confidential for your assurance that we comply with the Federal, State, and local laws on “Confidentiality of Medical Information.”

Patient Name (label)

ACKNOWLEDGEMENT

I, 
(patient, responsible party), acknowledge that I have received a copy of Colorado Allergy and Asthma Centers P.C.’s (the practice's) “HIPAA Privacy Notice-Patient Acknowledgment” document regarding protection of Personal Health Information (PHI).
Patient's or Responsible Party’s Signature:
SIGN WITH FINGER (PHONE/TABLET) OR WITH COMPUTER MOUSE.

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You may request at any time a detailed written policy of the Colorado Allergy and Asthma Center’s P.C., “HIPAA Privacy Notice- Detailed” or access it at www.coloradoallergy.com


Financial Policy

Please review this information and sign at the end of the document. By signing this document, the patient/responsibility party is accepting financial responsibility for all services provided.

Colorado Allergy and Asthma Centers (CAAC) will bill your insurance as a courtesy if the company is within the United States. We may provide an estimate of what your insurance company may pay. The insurance company makes the final determination of your eligibility and benefits.

It is your responsibility to notify our office of any patient information changes including address, name, and insurance information.
Insurance Accounts

  1. I (patient or financially responsible party) will disclose all insurance information including primary and secondary insurance at the time of service. Failure to provide complete insurance information may result in my responsibility to pay the entire bill.
  2. I agree to pay any portion of the charges not covered by my insurance within 10 days of the statement date. If CAAC is out of network with my insurance company, I will be responsible for any charges above what is paid by my insurance up to the CAAC set fee amount. If my insurance pays me directly, I agree to forward the payment to CAAC immediately.
  3. I am responsible for any co-payments, co-insurances, deductibles, plus any balance due on non- covered services not paid by my insurance at the time of service. Payments are required within the state’s time limitation for paying healthcare claims. The co-payment, co-insurance or deductible requirement cannot be waived. We accept cash, check or credit cards.


Self-Pay Accounts
If you do not have insurance or you choose to not utilize your insurance, we offer a self-pay discount of 25% if payment is received in full at the time of service. Self-pay accounts are for all services for the entire year, or until new insurance is initiated due to a qualifying event.
No Exceptions.

Referrals

  1. I am responsible for obtaining a referral, if required by my policy.
  2. I understand if I fail to obtain the referral and/or preauthorization there may be a lower payment or no payment from the insurance company. I will be responsible for the balance due.


Missed Appointments
I understand I may be charged a fee of $75.00 if I miss or cancel an appointment within 24 hours of the scheduled appointment.

Returned Checks
I understand I will be responsible for a fee of $35 for a returned check. This will be applied to my account in addition to the insufficient funds amount. All future payments must be paid with a debit/credit card or cash.

Medical Record Copies
I understand I will be responsible for a fee that follows Colorado Department of Health and Environment standard for requesting a copy of my health records.

Minor Patients

  1. By signing this document, I (the parent, guardian) accept financial responsibility for all services provided by CAAC, regardless of who is the subscriber of the insurance policy.
  2. I understand as the adult (parent, guardian) accompanying a minor, I am responsible for charges at time of service (such as co-payment or deductible).


A divorce decree does not determine which party Colorado Allergy and Asthma Centers, P.C. will bill for medical services. Divorce decrees are only binding upon the two parties who made the agreement.

Payments

  1. I understand that I am requested to put a credit, debit or HSA card on file. This information is kept strictly confidential and will only be used for payment of fees to CAAC. The card on file will not be charged until the insurance company has reviewed the claim. By processing insurance first, patients will know their exact out-of-pocket responsibility. After the insurance company has completed processing the claim, I will receive an email informing them of the actual amount owed. The email will explain that the card on file will be charged in 3-5 days unless I contact the billing office at 720- 858-7550.
  2. I understand the Financial Information may be provided to the financially responsible party (Guarantor), Subscriber, or the party paying the bill.
  3. I understand the financially responsible party (Guarantor) is responsible for payments
  4. I understand upon default, I am responsible for 24% per annum interest, cost of collections, and attorney fees, even if no lawsuit is filed.


Extended payment arrangements are available if needed. Please contact an Account Manager in our Patient Finance Office at 720-858-7550 to discuss payment options.

Please call our Patient Finance Office at 720-858-7550 with any questions or concerns.

I have read the policies above and understand and agree to this Financial Policy.
 

SIGN WITH FINGER (PHONE/TABLET) OR WITH COMPUTER MOUSE.

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Please only click the "Submit" button once, and be patient as the submit process can take a few moments to complete.