Date of Appointment
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.
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.
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
Your Rights under the Law:
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 refuse treatment via telemedicine visits
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.
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
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.
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.
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.
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.
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.
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.
For skin testing, hold any of the following medications or any other over-the-counter or prescription medication, containing an antihistamine, for at least 7 days:
Astelin (Azelastine), Astepro, Dymista, Patanase
Do not stop medication you have been prescribed for other chronic medical conditions, such as heart and lung problems, or inhaled medications for your chest or nose. Do not stop asthma medications. Do not stop Singulair.
Call prescribing doctor for instructions on holding the medications listed below. May interfere with skin testing. Hold for 5 days before appointment.
For Parkinson’s Disease, antihistamine properties
Some tranquilizers, cough medications, and sleeping aids may contain an antihistamine. If you have questions about the content of any medications, please call your doctor, pharmacist, or us.