PATIENT INFORMATION RECORD
Name: _____________________________________ Date of Birth: ____________Male/Female
First
Middle
Last
Marital Status: ___________ Social Security # [SS]xxx-xx-____________ Driver’s Lic: ______________
Mailing Address: ________________________________________ City, State, Zip: _________________
Phone: Home ____________________Work: ______________________Cell: ______________________
Employer: ________________________________________________________________Student: Yes/No
Spouse/Guardian Name: ______________________ Spouse/Guardian DOB: ________________________
Spouse/Guardian SS#___________________________ Phone #: __________________________________
Name of Family member who has been a Patient/Referring Physician: ______________________________
POLICY HOLDER INFORMATION:
Name of Insured: _________________________________________________________________________
Address: _________________________ City, State, Zip: _________________________________________
Phone: Home _______________________________ Work: _______________________________________
Relationship to Patient: __________________ SS# ___________________ DOB: ______________________
Employer Name & Address: _________________________________________________________________
Primary Insurance: _________________ Policy#/ID#: __________________ Group#: _________________
Secondary Insurance: _________________ Policy #/ID#: _________________ Group#: ________________
I certify that the above information is correct to the best of my knowledge.
Signature: _________________________________________ Date: ________________________________
ASSIGMENT AUTHORIZATION/OFFICE FEE POLICY
I request that any payment of authorized insurance benefit, be made on my behalf to Prem Menon MD & or
Vimla Menon MD for services furnished to me by these providers. I authorize Drs Prem Menon & Vimla
Menon to release information to my Insurance carriers as needed to determine the benefits payable for related
services. I understand that I am financially responsible for all charges (co-payment/ co-insurance/ un met
deductibles) at all times.
Date: _______________ Signature of Patient or Responsible Person: _________________________________
Responsible Person’s Relationship to Patient: ____________________________________________________
Emergency Contact Phone #: ______________________________________________________________
Name: ________________________________ Relationship: _______________________________________
Name of other person(s) authorized to sign/receive information regarding this Patient’s medical treatment
_________________________________________________________________________________________
5217 Flanders Drive ● Baton Rouge, LA 70808 ● (225) 766-6931 ● 1-800-DRMENON● FAX: (225) 766-9413
AAIC Asthma, Allergy & Immunology Center
PREM MENON, M.D.
VIMLA MENON, M.D.
Diplomates, American Board of Allergy and Immunology
Clinical and Diagnostic Immunology
Authorization for the use of Protected Health Information (PHI)
As required by the Health Information Portability and Accountability Act of 1996, The Asthma,
Allergy & Immunology Center (AAIC) may not use or disclose your protected health
information (PHI), except as provided in our Privacy/Disclosure Notice without your
authorization. Your signature on this form indicates that you are authorizing the uses and
disclosures of PHI described herein. You may revoke this authorization at any time by signing
and dating a revocation of Authorization for use of PHI form.
I, _________________________ (print name) hereby acknowledge that I have read and
understand the Privacy/Disclosure Notice provided by AAIC and hereby agree to the use, and
disclosure of protected health information that pertains to me.
OR
I, _________________________ (print name) hereby acknowledge that I have read the
nondisclosure notice. I understand I can request that AAIC not disclose my PHI related to a
specific service to my Health Plan. I understand there are limitations to my right for
nondisclosure. I have been provided with the explanation of the limitations and I understand
them.
____________________________
Patient/ Legal Guardian Signature
______________________________
Date
Legal guardian’s relationship to patient: _____________________________________________
____________________________
Witness
______________________________
Date
5217 Flanders Drive ● Baton Rouge, LA 70808 ● (225) 766-6931 ● 1-800-DRMENON● FAX: (225) 766-9413
AAIC Asthma, Allergy & Immunology Center
PREM MENON, M.D.
VIMLA MENON, M.D.
Diplomates, American Board of Allergy and Immunology
Clinical and Diagnostic Immunology
ASSIGNMENT OF INSURANCE BENEFITS
I hereby authorize direct payment of medical benefits to Dr. Prem Menon or Dr. Vimla Menon
for all services rendered by him/her in person or under his/her supervision.
I understand that I will be financially responsible for any balance due that is not covered by my
insurance company, whether it be applied to my deductible, co-insurance, co-payment of my
insurance carrier determines that the service(s) rendered are a non-covered benefit, coverage
terminated or any other valid reasons. I also understand that when my insurance coverage was
verified, they did not guarantee coverage or payment.
Patient Name: __________________________________________________________________
Patient/Parent/Legal Guardian: ____________________________________________________
Witness: ___________________________
Date: _______________________________
Revised 6/30/15
5217 Flanders Drive ● Baton Rouge, LA 70808 ● (225) 766-6931 ● 1-800-DRMENON● FAX: (225) 766-9413
AAIC Asthma, Allergy & Immunology Center
Authorization For Release of Medical Records
Patient’s Name: ____________________________________________DOB: ___________________
First
Middle
Last
Select I or II below:
I.
I authorize Dr. Menon to release my records to: _____________________________________
Physician’s Full Name
__________________________________________________________________________________
Street Address
City
State
Zip Code
II.
I authorize Dr. _______________________ to release my records to: (check one box below)

Prem Menon, MD

Vimla Menon, MD
5217 Flanders Drive
5217 Flanders Drive
Baton Rouge, LA 70808
Baton Rouge, LA 70808
Records should include the following sections: ______________________________________
(specify what part(s) of your records you would like sent/received (i.e. labs, progress notes, tests, all…)
for the period of: (specify time frame of records)___________________________________________
This authorization includes the release of detailed medical information (including, but not limited to), doctor
notes, hospital records, nurses notes, therapists notes, x-ray reports, lab test reports (including but not limited
to) HIV related condition, drug/alcohol abuse and/or psychiatric or psychological diagnosis. This release also
authorizes the release of any and all medical records received from any other healthcare facility or provider
unless otherwise specified above.
Any doctor, nurse, administrator, librarian and/or authorized staff member to whom this authorization is
presented, is hereby released from all legal liability or responsibility for release of such records and/or
information, because this document is a written authorization for release of medical information pursuant to
LA R. S. 13:3734 (E), whereby the undersigned, the patient or patient representative, waives all limitations and
restrictions on disclosure, dissemination and discussion of such records, and/or information. Once this
information is released, it will no longer be protected by the federal privacy law.
I understand that I am under no obligation to sign this authorization. I further understand that my ability to
obtain treatment will not depend in any way on, whether or not, I sign this authorization.
I, the patient or patient’s representative, hereby agrees that a photo static copy of this authorization may serve
as an original and that this authorization shall be valid and effective for one year from the above written date,
unless it is revoked by me in writing.
_____________________________________
Patient’s/Parent’s or Guardian’s signature
________________________________
Date
_____________________________________
Witness of above signature
________________________________
Date
Revocation section: __________________________________________________________________
5217 Flanders Drive ● Baton Rouge, LA 70808 ● (225) 766-6931 ● 1-800-DRMENON● FAX: (225) 766-9413
Primary and Secondary Insurance Information
Name: _______________________DOB:____________Acct #: ______________
Date
Revised
1st Insurance
2nd Insurance
Signature of Responsible Party
6/30/2015
5217 Flanders Drive ● Baton Rouge, LA 70808 ● (225) 766-6931 ● 1-800-DRMENON● FAX: (225) 766-9413
AAIC Asthma, Allergy & Immunology Center
CONSENT FOR DIAGNOSTIC PROCEDURES AND TREATMENT
ACKNOWLEDGEMENT
I authorize and direct Prem K. Menon M.D./ Vimla Menon M.D. or assistants of his/her choice
to perform upon:
______________________________________________________________________________
Patient’s name
DOB:
The following diagnostic procedure or procedures will be done only if the Doctor deems it
medically necessary.
Allergy skin testing with inhalant/food extracts or drugs/stinging insect venom.
In general terms, the nature and purpose of this diagnostic procedure is to inject small quantities
of the extracts into the skin, in order to produce a localized wheal (swelling) and flare (redness)
reaction to determine your sensitivity (allergy) to any of the injected material.
Allergen Immunotherapy (allergy shots) involve injections of serial and increasing
concentrations of special extracts (serum). The extracts are prepared with the allergens (e.g.
dust, mold spores, pollens or venoms) that a person is found to be allergic to. The dose and
concentration of the extract is gradually increased based on his/her ability to tolerate the
injections without developing a localized or generalized systemic reaction.
Some risks known to be associated with skin testing and allergy shots are:
Syncope (fainting); hives (welts); skin swelling; generalized red skin; wheezing; loss of limb
function, acute exacerbation (made worse) or pre-existing conditions such as heart disease,
hypertension, epilepsy, stroke, asthma, etc.; shock (collapse); anaphylaxis (sudden severe
generalized allergic reaction); seizures; heart attack; stroke and even death.
I hereby authorize and direct Prem K. Menon M.D./ Vimla Menon M.D., or their assistants to
provide such additional services as they may deem reasonable and necessary including, but not
limited to, the treatment of severe allergic reaction in a hospital emergency room, using services
of the X-ray department, laboratories, or hospitalization and I hereby consent thereto.
Follow up appointments are essential for continued patient care. During these visits, your
response to medication and/or allergy shots, laboratory tests, x-ray or CT scan results are
discussed at length and additional recommendations are made. Need for referral to other
specialists, if necessary will also be considered. The Physicians and AAIC staff will not be
responsible for the risks involved to the patient due to noncompliance of treatment, missed
appointments, and or by not obtaining the tests or procedures previously ordered.
5217 Flanders Drive ● Baton Rouge, LA 70808 ● (225) 766-6931 ● 1-800-DRMENON● FAX: (225) 766-9413
I understand that it is my responsibility to enquire or call to get the results of my laboratory
tests, x-rays, or CT scans that are not performed at Drs. Prem Menon/Vimla Menon’s office.
Drs. Prem K. Menon and Vimla Menon are consultants in Asthma, Allergy and Immunology.
ALL PATIENTS UNDER THEIR CARE ARE EXPECTED TO HAVE THEIR OWN PRIMARY
CARE (Family physician, internist, or pediatrician) PHYSICIANS. In the event that you or your
child requires Emergency Room care or hospitalization, you should contact your primary care
physician. If your physician so desires, he or she may consult Dr. Menon.
I understand that this consent must be signed in order for Dr. Prem Menon or Dr. Vimla Menon
to examine, evaluate and treat me (perform skin tests, lung function tests ,order x-rays, blood
tests and prescribe medications).
I hereby state that I have read and understood this consent. This consent form is valid until
revoked by me in writing.
______________________________________________________________________________
Signature of Patient
DOB
Date
Time
______________________________________________________________________________
Signature of relative or representative (when required)
__________________________________________
Witness
__________________________________________
Physician
Revised June 30, 2015
5217 Flanders Drive ● Baton Rouge, LA 70808 ● (225) 766-6931 ● 1-800-DRMENON● FAX: (225) 766-9413