ALLERGY & ASTHMA CONSULTANTS P.C.
Mohan Dhillon, M.D.
Alan Geller, R.P.A.-C
Ph: 607-729-0726
Fax: 607-729-1341
www.broomeallergy.com
104 Old Vestal Rd.,Suite #108
Vestal, NY 13850
An appointment is scheduled for:________________________________________________________
on __________________________ at _____________ am/pm.
48 hours prior to your appointment, you can cancel or reschedule by calling our office at 607-729-0726
PATIENT RESPONSIBILITIES: Bring your paperwork already completed. You can
contact us anytime if you have any additional questions. Be advised, if you arrive
unprepared the Doctor may choose to have your appointment rescheduled.
INSURANCE: Bring all cards or information with you. If you do not bring them, you will be listed as a self
pay patient, and your payment will be due the day of your visit by cash or credit card only.
ALLERGY TESTING: If you are scheduled for allergy testing, do not take any medication containing
decongestants or antihistamines five days prior to your scheduled appointment, or you cannot be tested.
HIVES: Patients with hives, please continue to take your medication as you cannot be tested during an
outbreak, and if appropriate, will be scheduled for testing in the future.
CANCELLATION / NO SHOW POLICY: If you no show or cancel a new patient appointment three times,
we will not schedule you again. Your primary or referring doctor will also be notified.
SELF PAY OR INSURANCE CO-PAYS: Payments are due day of visit unless prior arrangements are made.
All self pay patients are by cash or credit card only, we will not accept checks. We accept Master Card / Visa
only.
INSURANCE REFERRALS: This office is not responsible for obtaining or tracking down referrals. Patients
must contact their primary care doctor for referrals and are to be received by our office prior to your visit.
(This is also true for yearly renewals of referrals.) Any dates not covered by a referral will be turned over to
the patient for payment.
If you are not sure if you need a referral, call the customer service phone number located on your insurance
card. You can also ask them benefit information on: allergy testing, specialist office visits co-pays, allergy
shots, and yearly deductibles. Each plan is different and we do not know the specifics of your insurance.
Please visit our web address located at the top of this paper to familiarize yourself with our practice and
important information on allergies & asthma. There is also a map link if you are unsure of our office location.
Sincerely,
Allergy & Asthma Office Staff
ALLERGY & ASTHMA CONSULTANTS P.C.
Mohan Dhillon, M.D.
Alan Geller, R.P.A.-C.
4104 Old Vestal Rd., Suite #108
Vestal, NY 13850
Ph: 607-729-0726, Fax: 607-729-1341
www.broomeallergy.com
Date:______________________
Patient Name:__________________________________
We participate with most major insurance plans. Some insurances mandate that you see doctors
specifically listed for your plan. If you are unsure if we are listed with your plan, do not call our
office. You must call the customer service number listed on your card or visit their web site. This is
especially important if we are considered “out of plan” or “out of your service area.”
1. Referrals are due before or during your visit, or the patient will be responsible for payment.
2. Co-pays are due day of visit, this includes office visits, shots and/or testing.
3. Medicaid patients MUST bring their card to be swiped for any service.
If you have any further questions, please call our office.
By signing below, I am acknowledging that I have read the above information. I am aware that I will
be held responsible for balances on my account due to deductibles, co-pays or out of network
expenses.
Patient or Guardian Signature:_______________________________________________________
Relationship to patient (if required):__________________________________________________
ALLERGY & ASTHMA CONSULTANTS P.C.
Alan Geller, R.P.A.-C.
4104 Old Vestal Rd., Suite #108
Vestal, NY 13850
Ph: 607-729-0726, Fax: 607-729-1341
www.broomeallergy.com
Patient Information (PLEASE PRINT)
Mohan Dhillon, M.D.
Patient First & Last Name:
Marital Status:
Date of Birth:
/
Age:
/
Street Address:
City, State & Zip
Parent Name (if patient is a minor):
Address:
Employer Name
Employer Address:
Sex:
Social Security No.
M/F
Home #
_________________________
Cell #
Home #
_________________________
Cell#
Work Number:
NAME OF PERSON WHO CARRIES THE INSURANCE ( IF THE INSURANCE IS UNDER THE NAME OF A
MINOR CHILD, PLEASE FILL OUT WHO THE CHILD RESIDES WITH )
Insured Name:
Date of Birth:
Social Security #
Relationship to Patient:
Address (if different than patient)
City, State & Zip
Home #
________________________
Cell #
Employer & Address:
City, State & Zip
Work #
/
/
Insurance Name: ______________________________________ Id#___________________________________ Group#__________________
Specialist Co-Pay Amount $____________________________
Billing Address:
(usually on back of card) ________________________________________________________________________________________________
Referring Doctor:
Address
City, State & Zip
Phone #
Private Insurance Authorization for Assignment of Benefits and Information Release:
I, the undersigned, authorize payment of medical benefits to ALLERGY & ASTHMA CONSULTANTS, P.C. for any services
furnished to me by the physicians. I understand I am financially responsible for any amount not covered by my contract. I also
authorize you to release to my insurance company information concerning health care, advice, treatment or supplies provided to me.
This information will be used for the purpose of evaluating and administering claims of benefits.
Date:_________________________ Patient Signature:________________________________________________________________________
MEDICARE LIFETIME SIGNATURE ON FILE:
I request that payment of authorized Medicare benefits be made either to me or on my behalf to ALLERGY & ASTHMA
CONSULTANTS P.C. for any services furnished to me by the physicians. I authorize any holder of medical information about me to be
released to The Health Care Financing Administration and its agents any information needed to determine these benefits or benefits
payable for related services.
Date:_________________________ Patient Signature:________________________________________________________________________