Allergy & Asthma Center of Boerne
Please Print Clearly
Dr. David Fuentes
Patient Information:
First Name: _______________________ Middle: _______________Last: _______________________________________
Address: _______________________________City, State, Zip: ___________________ Date of Birth: _______________
□ Male □ Female
Marital Status: □Single □Married □Divorced □Widowed
Race: __________ Ethnicity: __________
Preferred Phone:
□ Home □ Work □ Cell
_________________________________________________
Secondary Phone:
□ Home □ Work □ Cell
_________________________________________________
E-Mail Address _________________________________________________________________________________
Preferred Pharmacy: _________________________________
Social Security Number: ______________________
How did you hear about Allergy & Asthma Center of Boerne? ________________________________________________
Family or Primary Care Physician: ________________________________________________________________________
Employment Status: □ Full-Time □ Part-Time □ Retired □ Self-Employed □ Full-Time Student □ Part-Time Student
Employer Name: ________________________________________________________________________________
Primary Insurance Information:
Secondary Insurance Information:
Plan Name:
Plan Name:
_______________________________
_________________________________
Member ID No: _______________________________
Member ID No: _______________________________
Group No:
Group No:
_______________________________
_________________________________
Policy Holder: _______________________________
Policy Holder: _________________________________
Policy Holder DOB: ___________________________
Policy Holder DOB: ____________________________
Emergency Contact:
Full Name:
______________________________________________________________________
Relationship to Patient: ______________________________________________________________________
Preferred Phone:
□ Home □ Work □ Cell
______________________________________________
Please Sign & Date Below:
I authorize the release of any medical or other information necessary to process my claims.
I request payment of medical (including government) benefits for services provided to me in the event assignment has been accepted.
Signature of Patient or Legal Guardian: __________________________________________________Date: _______________________
Primary Caregiver Information for Minor Child Aged 0-17 Years Old If Other Than Policyholder:
First Name: _______________________Middle Name: _____________________Last Name: _____________________
Address: ___________________________________City, State, Zip: _________________________________________
Date of Birth: _____________
Preferred Phone# & Type:
Social Security Number: ___________________
_______________________________ □ Home
Gender: □ Male □ Female
□ Work
□ Cell
Employer Name: ________________________________________
Marital Status:
□ Single
□ Married
□ Divorced
□ Widowed
Employment Status: □ Full-Time □ Part-Time □ Retired □ Self-Employed
E-Mail Address _____________________________________________________________________________________
Allergy & Asthma Center of Boerne
Payment & Collections Policy
All Patients Please Read Carefully & Initial
________
I understand eligibility and benefits are verified prior to my initial appointment and that I am required to pay any copay,
deductible, and/or cost-share that my insurance has quoted due and payable by me at the time of service. I understand this
quote is not a guarantee of payment and that plan benefits may differ once my claim is processed. I understand that the Allergy
& Asthma Center of Boerne can only rely on the information quoted to them. I agree to immediately notify your office if I have a
scheduled appointment or prior to scheduling appointments if my insurance plan has changed.
________
I understand all claims are subject to review prior to plan payment, and that this may include a review for
Pre-existing conditions. I agree to pay in full for services denied due to a pre-existing condition.
________
I agree that in the event my account is sent to collections for unpaid charges that are approved by my insurance then I am
responsible for all charges applied by a collection agency and/or attorney’s office. I understand the current amount charged to
The Allergy & Asthma Center of Boerne by their collection agency is 25% to 35% of the total balance. I agree to pay for all
collection efforts related to my account.
Patients with Managed Care Plans Please Read Carefully & Initial
________
I understand if my insurance plan requires a referral to be issued by my selected Primary Care Doctor in order for a specialist to
receive payment, then it is my responsibility to inform your office prior to scheduling appointments. I understand that I have the
option to pay as a private pay patient should I not desire to obtain a referral, but that MY insurance will not be filed and my out of
pocket cost will be substantially more
Patients with More Than One Insurance Plan Please Read Carefully & Initial
________
I understand if I have a commercial primary or secondary plan (Does not apply to Federal or State Plans) that I will be expected
to pay all costs not paid by my primary at the time of service, This includes unmet deductibles, cost-share, and copays. Note:
Your secondary will be filed by our office as a courtesy. Any overpayment by you will be refunded promptly after the secondary
has processed all claims.
________
By initialing on this line, you hereby acknowledge you have read and understand the section below:
Strict and standardized guidelines are set by all commercial, state, and federal insurance plans for the purpose of
determining an individuals correct primary, secondary, and (if applicable) tertiary insurance plan. This enables each plan to
properly coordinate benefits (Known officially as Coordinate of Benefits or COB)
Under no circumstances are policyholders allowed to decide the order of their primary/secondary/tertiary plan, but are legally
obligated to contact the member services department for each carrier. Once notified the carriers will determine their status and
also inform you of the correct order claims must be filed by every individual provider of service you seek services from.
Failure to notify each plan as required will result in costly, unnecessary, and intensive labor efforts by the staff of the Allergy &
Asthma Center of Boerne in order to obtain proper payment for your services. Therefore it is our policy to bill the responsible
party for any refunds issued due to the failure to notify other carriers and/or our office of coverage that has not been reported or
disclosed at this time. You will be refunded you promptly when/if the correct policy determines they will pay.
Patients with Health Savings Account or Credit Card on File
________
In the event I have provided the necessary information to the Allergy & Asthma Center of Boerne. I hereby give permission for
my Health Savings Account Plan or Credit Card on File to be charged automatically for any balance my insurance company
determines to be my responsibility after claims are processed.
Print Patient Name: ________________________________________________________DOB: ____________
Patient or Guardian
Signature:
________________________________________________________Date: _____________
The Allergy and Asthma Center of Boerne
David Fuentes, M.D. FACAAI
________________________________________________________________________
I understand that as part of my healthcare, The Allergy and Asthma of Boerne originates and
maintains health records describing my health history, symptoms, examination and test results,
diagnoses, treatment, and any plans for future care of treatment. I understand that this
information serves as:
●
A basis for planning my care and treatment
●
A means of communication among the many health professionals who contribute
to my care
●
A source of information for applying my diagnosis and surgical information to my bill
●
A means by which a third-party payer can verify that services billed were actually
provided
●
A tool for routine healthcare operations such as assessing quality and reviewing the
competence of healthcare professionals
I have been offered a complete copy of this Notice of Privacy Practices which provides a more
complete description of protected health information uses and disclosures. I understand that The
Allergy and Asthma Center of Boerne reserves the right to change its practices and to make
the new provisions effective for all protected health information maintained by The Allergy and
Asthma Center of Boerne. I also understand that Dr. David Fuentes may review my records to
determine and to discuss possible qualification in research studies for which he is the lead
investigator or the sub-investigator at his medical research facility TTS Research.
______________________________________
Signature of Patient or Legal Representative
________________________
Date Signed
______________________________________
Signature of Employee Witness
________________________
Date Signed
The Allergy and Asthma Center of Boerne was unable to obtain acknowledgement or
consent because:
□ Emergency
□ Patient Non-Responsive □ Patient Sedated
□ Patient Confused/Disoriented
Effective 7/1/2003
□ Refused- Reason: _______________________
Revision 09/24/11
Allergy & Asthma Center of Boerne
Dear Patient,
Our office will begin using text messages to communicate certain information to our patients. This information
will include hour changes or office closures to our shot patients and appointment reminders to every patient. In
some instances a mass email may be distributed.
Please be aware that if you do not have unlimited text messaging your carrier may charge a nominal fee if you
exceed your plans limit.
Please remember to update your contact information in the event your phone numbers, email or mailing address
changes at any time.
Please provide your current email address and an authorized signature:
□
Please email me at:
___________________________
I hereby authorize the Allergy & Asthma Center of Boerne to send email messages to my account, listed
above.
Printed Name of Patient: ________________________________________________
Printed Name of Patient: ________________________________________________
Printed Name of Patient: ________________________________________________
Authorized Signature: ____________________________________________
Date: _________________
If you would prefer to be called please provide the primary phone number that you wish
to be reached at:
□
Please ONLY contact me by telephone at:
____________________
Authorized Signature: ____________________________________________
Date: __________________