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1 ADULT PATIENT REGISTRATION FORM

(Please Print)

Personal Information

Name: _______________________________________ Street Address: _______________________________________

City: _______________________________ State: ______ ZIP: _______________ Hm. Phone: ___________________

Social Security No. ________/______/________ Sex: ______ Marital Status: _____ Date of Birth: ________________

Your Employer: _____________________________________ Work Phone: ______________________

In Case of Emergency Notify: ______________________________________/_______________________

(Name) (Phone)

Primary Care Physician: ________________________________________________ Phone: ______________________

**************************************************************************************************

INSURANCE INFORMATION

(Please Present All Insurance Cards to Staff)

Primary Carrier: ___________________________________

Subscriber’s Name: ______________________________________ Relationship to Patient: _______________________

Billing Address (if other than patient’s): _________________________________________________________________

Contract No. ____________________________________ Group No. _________________________

Referral Authorization No. _________________________ Co-pay Amount (if any) $____________

Employer Name: __________________________________________

Employer Address: ______________________________________________________ Phone:_____________________

Secondary Carrier: ___________________________________

Subscriber’s Name: ______________________________________ Relationship to Patient: _______________________

Billing Address (if other than patient’s): _________________________________________________________________

Contract No. ____________________________________ Group No. _________________________

Referral Authorization No. _________________________ Co-pay Amount (if any) $____________

Employer Name: __________________________________________

Employer Address: ______________________________________________________ Phone:_____________________

CHILD/DEPENDANT REGISTRATION FORM

(P l e a s e P r i n t)

Personal Information

Patient’s Legal Name: _______________________________ Street Address: __________________________________

City: _______________________________ State: ______ ZIP: _______________ Hm. Phone: ___________________

Social Security No. __________/________/__________ Sex: _____________ Date of Birth: _____________________

In Case of Emergency Notify: _____________________________________________/___________________________

(Name) (Phone)

Primary/Referring Physician: ___________________________________________ Phone: ______________________

Mother’s Legal Name: ___________________________________ Social Security No. __________________________

Home Phone: __________________________ Work Phone: ___________________________

Father’s Legal Name: ___________________________________ Social Security No. __________________________

Home Phone: __________________________ Work Phone: ___________________________

IF BOTH PARENTS HAVE INSURANCE, THE FOLLOWING INFORMATION IS REQUIRED:

Father’s Date of Birth: __________________ Mother’s Date of Birth: ___________________

**************************************************************************************************

INSURANCE INFORMATION

(Please Present All Insurance Cards to Staff)

Primary Carrier: ________________________ Subscriber’s Name: _____________________________________

Relationship to Patient: _______________________ Subscriber’s Address:____________________________________

Date of Birth: ___________ and Social Security Number: _______________

Contract No. ____________________________________ Group No. _________________________

Referral Authorization No. _________________________ Co-pay Amount (if any) $____________

Employer’s Name:_____________________________________________

Employer’s Address:___________________________________________________ Phone:_______________________

Secondary Carrier: ______________________ Subscriber’s Name: _____________________________________

Relationship to Patient: _______________________ Subscriber’s Address:____________________________________

Contract No. ____________________________________ Group No. _________________________

Referral Authorization No. _________________________ Co-pay Amount (if any) $____________

Employer’s Name:_____________________________________________

Employer’s Address:___________________________________________________ Phone:_______________________

FINANCIAL POLICY

Thank you for allowing us to be part of your and/or child’s health care team. In order for us to provide the best possible care and to maximize your medical insurance policy coverage, you must provide accurate insurance information. This includes providing current insurance card(s) and informing our staff of any recent changes, including employment, coverage, or address.

The relationship you have with your insurance company and employer is a contract of which we are not part of. As a courtesy, our billing staff will process your claims for you, and answer any questions you may have. Please be advised that, regardless of your insurance status, final responsibility for payment of our services is your obligation.

It is the patient’s responsibility to assure that all necessary referrals and authorizations are made by the primary care physician and also any renewals, if required.

Patients with Blue Cross Blue Shield Master Medical (BCBSM) are required to pay at the time of service. We will process your claim promptly in order for you to receive payment directly from BCBSM.

**Special Note** for General Motors BCBS PPO Groups: Your plan will cover a portion of the Office Call. For Traditional Groups: Your plan does not cover Office Calls. All other services, including skin testing, serums and injections, are not covered by either plan.

Co-payments are due at the time of service. If you cannot pay the co-payment, please notify the receptionist.

We will make every attempt to notify you of your insurance coverage for our services, however, we cannot guarantee coverage for every service. Certain services, such as office calls, serums, injections, or testing may not be covered by your insurance.

The parent who REQUESTS treatment for a child is the parent responsible for all fees for services rendered.

I have read and understand the conditions set forth, and I authorize the treatment of myself and/or my child and also release of any medical or other information necessary to process the claim(s). I also request payment of medical benefits to be made directly to Okemos Allergy Center, P.C.

______________________________________________ ________________________

Responsible Party/Subscriber Date

Okemos Allergy Center, P.C.

Please Answer Questions that Apply to You or Your Child

Patient’s Name: ___________________________________________________ Date: _________________________

1. What are your symptoms? Mark an “X” after any of the following which apply to you. Mark “XX” if severe and “XXX” if extremely severe.

X Onset Date X Onset Date X Onset Date

___Coughing _________ ___Nasal Blockage ________ ___Sore Throat _________

___Wheezing _________ ___Runny Nose _________ ___Itchy Throat _________

___Shortness of Breath________ ___Sneezing _________ ___Headaches _________

___Chest Pain _________ ___Post-Nasal Drainage _________ ___Eye Itching _________

___Skin Itching _________ ___Itchy Nose _________ ___Tearing _________

___Skin Rash _________ ___Nose Bleeds _________ ___Ear Blockage _________

___Hives or Swelling_________ ___Loss of Taste or Smell _________ ___Hearing Loss _________

___Nausea/Indigestion_______ ___Diarrhea _________ ___Colic/Cramps _________

___Vomiting _________ ___Frequent Colds _________ ___Hoarseness _________

___Fatigue _________ ___Nervousness _________ ___Insect Reactions_________

Other: _________________________________________________________________

2. Which symptom(s)is the most bothersome? _______________________________

3. Do you have a history of any major disease?_____________________________

________________________________________________________________

4. List hospitalizations:

Reason Date

1. _______________________ ___________________________

2.________________________ ___________________________

3.________________________ ___________________________

5. Do your symptoms change with the seasons? Which season(s) are worse:______________________________

__________________________________________________________________________________________

6. Does any of the following affect your symptoms:

dxddxd

In air conditioning Worse_____ Better_____ No Change_____

When outdoors Worse______ Better_____ No Change_____

When indoors Worse______ Better_____ No Change_____

At night Worse______ Better_____ No Change_____

On exposure to house dust Worse______ Better_____ No Change_____

Sleeping on feather pillows Worse______ Better_____ No Change_____

On exposure to freshly cut grass Worse______ Better_____ No Change_____

In fields or tall weeds Worse______ Better_____ No Change_____

In barns, near hay

or raking leaves Worse______ Better_____ No Change_____

After exposure to animals Worse______ Better_____ No Change_____

On exposure to tobacco smoke Worse______ Better_____ No Change_____

On exposure to hair spray,

perfume or newsprint Worse______ Better_____ No Change______

During or after exercise Worse______ Better_____ No Change______

7. List foods that you suspect cause symptoms and describe:

________________________________________________________________

________________________________________________________________

8. List all drugs which cause symptoms

Drug Symptoms

_________________________________________________________________

________________________________________________________________

_________________________________________________________________

9. How do you feel while on vacation?

Worse______ Better_____ No Change______

10. In the past year, how many episodes of infection have you had? (Yellow drainage or sputum, fever, body aches, strep throat, middle ear infection, pneumonia)

None_____ 1-2 ______ 3-4 _____ 4-7_____ Over 12 ______

11. Have you ever smoked? How much? ________________________

Age Started______ Age Stopped______________________

Does anyone in the house smoke? _____________________________________

12. What type of work do you do? Please describe________________________________________________________

13. How do you feel at work when compared to home?

Worse______Better______ No Change_______

14. Have you had any lab work done recently? Blood tests, urine tests, X-rays?

__________________________________________________________________________________________

15. What Questions do you have regarding allergy? ______________________________________________________

Patient Information

This practice is limited to the diagnosis and treatment of allergic diseases and related medical problems. The field of clinical allergies is a complex one and it requires thorough and time-consuming history for best results. It is the desire of this office to provide you with the finest allergy care available. We will try to do this in a friendly, efficient and economical manner. We appreciate any suggestions you may have to improve our services.

Your Initial Visit

Most patients come to this office by referral from their pediatrician, internist, family physician or other physician. The purpose of this visit is to obtain a detailed history, adequate physical examination and preliminary lab work necessary to establish whether allergy therapy is indicated. The mechanics of an allergic evaluation will be discussed and a course of treatment outlined. If it is felt that you would benefit from allergy therapy, a skin test will be done. Please fill out the attached questionnaire prior to your initial visit and bring it with you. As you go through the questions, you may find many which you may not be able to answer without referring to your health records or without consulting other family members. If you are currently taking any antihistamines, please refer to the enclosed medications list for proper instruction on discontinuing antihistamines prior to your appointment. PLEASE REMAIN ON ALL OTHER MEDICATIONS other than those listed. Please call our office if you have any questions regarding stopping medications. If you are unable to keep your appointment or would like to change it, please give us a 24-hour notice.

Skin Tests

Skin testing can usually be accomplished in one visit (1 ½ to 2 ½ hours). Occasionally, more than one visit is required. Two types of tests are performed: 1. Prick Tests (which are performed on the back). 2. Intradermal Tests (which are performed on the arm). The number of tests varies depending on the patient. If a child is to be tested, we will be happy to demonstrate each type of test on the parent, if desired. The tests are read in 15 to 20 minutes after application. Following the skin tests, the results will be discussed with you, as well as initial impressions, and your future care. If it is necessary for you to receive allergy shots, your program will be outlined.

Appointments

Occasional follow-up visits may be necessary and also appointments if you are ill. WE ASK THAT YOU CALL THE OFFICE FOR AN APPOINTMENT. For other medical problems, we request that you contact your family physician. However, in an emergency situation, we will do whatever is necessary to care for your problems and will see you as soon as possible.

Patients who receive their allergy injections at their family physicians’ office will need to contact our office to schedule an appointment when they need new serum. The first dose in the new bottle of serum will be administered during that visit and the doctor will review the patient’s progress.

Patients who receive their allergy shots at our office will be required to schedule periodic evaluations. At this time, the doctor will have an opportunity to assess how successful the treatment program has been and make any additional recommendations for treatment. Additional skin testing may also be indicated, depending upon any changes in symptoms. Patients who receive shots in the office will not need to schedule appointments in order to receive their shots. Please come to the office during the hours listed below and sign-in at the Injection Window. Our busiest time is from 3:30 p.m. until closing. If it is impossible for you to avoid these busy times, please be aware that we will do our best to care for all patients as soon as possible. ALL PATIENTS ARE REQUIRED TO REMAIN IN OUR OFFICE FOR 20 MINUTES FOLLOWING EVERY INJECTION to check for any reactions. Please consider this when timing your visit.

Hours: Monday 1:00 to 5:30 p.m.

Tuesday 7:00 a.m. to 10:00 a.m.
1:00 to 5:30 p.m.

Wednesday 9:00 to 11:00 a.m.

1:00 to 6:30 p.m.

Thursday 1:00 to 5:30 p.m.

Friday 1:00 to 5:30 p.m.

Office Billing Policy

We participate with the following insurance plans: PHP, Blue Cross Blue Shield, Blue Care Network, Medicare, Blue Choice, Blue Preferred Plus, PPOM, SPHN, MCare, MIDNET, Federal BCBS, Medicaid, McLaren Medicaid, and PHP Medicaid.

Some of these carriers require prior authorization from your primary care physician. Failure to obtain authorization will result in no coverage or reduced coverage for our services. You will be responsible for any co-pay or deductible as determined by your carrier at the time of service.

It is the responsibility of the patient to know the terms of their own coverage. We will be happy to assist to the best of our ability to answer coverage questions.

We are participating with Blue Cross Blue Shield of Michigan and we will bill your services directly to BCBS. You will be responsible for any co-pay or deductible amounts determined by BCBS. Not all BCBS plans have coverage for allergy-related services. Should you have questions regarding eligibility, deductible or benefits, please contact BCBS.

For commercial insurance carriers which we do not participate with, we will submit claims on your behalf and accept assignment (payment) directly. You will be billed for any amount not covered by your insurance plan.

We anticipate that all accounts with balances will be paid on a timely basis, regardless of the status of insurance claims. The majority of claims are processed within 30 to 45 days. If you have not received an acknowledgment from your carrier, be sure to contact our office so we can re-bill your claim.

Because of the ever-changing status of families, such as divorce, separation and single parents, the parent who requests treatment for the child is responsible for the fees incurred.

We will coordinate billing between two insurance carriers when we participate with both carriers. If we do not participate with the primary carrier, but do so with the secondary carrier, you will need to provide the original EOB’s (explanation of benefits) from the primary carrier so that we can bill the secondary carrier.

Our fees are comparable to those charged by other specialists in this area. We will be happy to discuss all charges for our services at any time and we will gladly answer all your questions. You will receive a monthly statement showing all transactions on your account if you have a balance due. In the event you are unable to pay your bill in full, regular payments can be arranged. If there are any unusual circumstances which prevent you from making payments, please contact our billing manager. We are willing to cooperate with you in any way we can, but cannot do so if you do not ask for assistance. Delinquent accounts may be referred to an outside collection agency.

Co-Payments are due at the time of service.

TO OUR PATIENTS WHO ARE TO BE SKIN TESTED

Antihistamines and many other medications can interfere with allergy skin testing. Before your visit, please discontinue the following medications for the number of days indicated:

A

DO NOT STOP

TAKING YOUR

ASTHMA MEDICATIONS

NTACIDS:

2 Days: Axid, Pepcid, Tagamet, Zantac

Do not need to stop: Prevacid, Prilosec, Nexium

ANTI-ANXIETY/DEPRESSANTS:

1 Day: Limbitrol
2 Days: Serequel

3 Days: Elavil (prefer 7 days), Remeron

7 Days: Sinequan (Doxepin)

ANTI-NAUSEA MEDICATIONS:

3 Days: Antivert, Compazine, Dramamine, Phenergan, Tigan

ANTI-HISTAMINES:
2 Days/Prescription: Allegra 60 mg, Allegra-D, Astelin Spray, Bromfed, Deconamine, Dimetane, Kronofed, Nolamine, Ornade, Rynatan, Ryna-S 12, Semprex, Trinalin, Fexofenadine 30 mg & 60 mg., Seroquel.

2 Days/Over-the-Counter: Actifed, Benadryl, Brompheniramine, Chlor-Trimeton, Chlorpheniramine, Clemastine, Contac, Dimetapp, Diphenhydramine, Drixoral, Tavist, Excedrin PM
5 Days/Prescription: Allegra 180 mg., Atarax, Periactin, Vistaril (Hydroxyzine), Zyrtec, Flexeril, Fexofenadine 180 mg., Allegra D 24 Hr., Zyrtec D.
5 Days/Over-the-Counter: All types of Claritin, Alavert, Loratadine
6 Days/Prescription: Clarinex, Clarinex D.

There is no need to discontinue decongestants unless they are combined with antihistamines. Asthma medications must be continued, as they do not interfere with allergy testing.

BETA BLOCKERS:

Patients taking beta blockers should not be skin tested. They are used to treat high blood pressure, migraine headaches, tremor, and certain heart problems. Please let us know if you are taking beta blockers before your visit. Do not discontinue beta blockers. They must be discontinued gradually, and skin testing may not be possible for patients who need to stay on these medications. Beta blocker drugs include:

Acebutolol

Atenolol

Betapace

Betaxolol

Bisoprolol

Blocadren

Brevibloc

Carteolol

Cartrol

Carvedilol

Coreg

Corgard

Corzide

Esmolol

Inderal

Inopran

Kerlone
Labetalol

Levatol

Lopressor

Metoprolol

Monitan

Nadolol

Normodyne

Penbutolol

Pindolol

Propranolol

Rhotral

Rythmol

Sectral

Sotalol

Tenoretic

Tenormin

Timolide

Timolol

Toprol

Trandate

Visken

Zebeta

Ziac

Eye Drops: Betagen, Betoptic, Cosopt, Levobunolol, Timoptic
*** Please call our office if you have any questions about these or other medications.

Okemos Allergy Center, P.C.

Guarantee of Payment for Services

In the interest of providing you with uninterrupted quality medical care, we are advising you of the following:

There are some insurance companies (i.e. SPHN, Medicaid HMO’s, Aetna Managed Care, Tri-care) that require an authorization before an office visit will be approved and paid for; others have their own guidelines about when a visit to a specialist’s office will be covered. It is your responsibility to know the extent of your insurance plan’s benefits and to get any required authorization/referral in advance of being seen. These authorizations/referrals must be in our office at the time of your visit.

If for any reason, your insurance company chooses not to cover your visit, or any procedures, you will be responsible for payment at the time of service. This includes all future visits. The estimated cost for a visit will be provided upon request.

Your signature below indicates that you will be responsible for payment in full should you fail to obtain an authorization/referral or should your insurance company choose not to pay for your visit.

I, ________________________________________, have read and agree with the above statement, and further agree to be responsible for all charges incurred, or to provide written approval authorization from my insurance company for all visits and procedures prior to being seen.

_____________________________________ ________________

Patient Signature Date

_____________________________________ ________________

Parent/Guardian Signature Date

Okemos Allergy Center, P.C.

Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. We are required by law to give you this notice. Please read and review this information. If you have any questions about this notice, you may contact our Privacy Officer. You may keep this copy of this notice for your records.

This notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your right to access and control your Protected Health Information. “Protected Health Information” is information about your health, health status, and the health care and services you receive at this office.

We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice at any time. This notice will be effective for all Protected Health Information that we maintain. We will post any changes and will provide you with a copy of the changes at your request.

Uses and Disclosures of Protected Health Information

You will be asked by our office to sign an acknowledgement form indicating that you have received the Privacy Practice Notice. If you choose not to sign the acknowledgement form, it will not delay any treatment you receive, but will be noted in your medical record. Your Protected Health Information may be used or disclosed by your physician, our office staff and others outside our office that are involved in your care for the purpose of providing health care services to you. Your Protected Health Information may also be used and disclosed to pay your health care bills and to support the operation of the practice.

Following are examples of the types of uses and disclosures of your Protected Health Information that the physician’s office is permitted to make.

Treatment: We will use and disclose your Protected Health Information to provide, coordinate, or manage your health care and any related services. This includes the coordination of management of your health care with physicians, nurses, technicians, office staff, or other personnel that are involved in your care. Examples: a home health care agency that provides care to you, or other physicians who may be treating you. Your Protected Health Information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose and treat you. Different personnel in our office may share your Protected Health Information to people who do not work in our office, such as phoning in prescriptions to your pharmacy, scheduling lab work or x-rays.

Payment: Your Protected Health Information will be used, as needed, to obtain payment for your health care services. This information will be used to bill you, an insurance company, or third party. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you such as: making determination of eligibility; coverage of benefits; reviewing services provided to you for medical necessity; and undertaking utilizations review activities.

Health Care Operations: We may disclose, as needed, your Protected Health Information in order to support the business activities of our practice. The activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students and licensing.

In this office we use a sign-in sheet at the registration desk where you will be asked to sign your name. We will also announce your name in the waiting room when the physician is ready to see you, or when we are ready to administer your allergy injection. We may also contact you to remind you of your appointment. If we are unable to speak with you, we will leave a message on an answering machine or with the individual at your home number.

We will share Protected Health Information with a third party “business associates” that perform various activities (e.g., billing, transcription services) for the practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of your Protected Health Information, we will have a written contract that contains terms that will protect the privacy of your Protected Health Information.

Others Involved in Your Health Care: Unless you object, we may disclose to a member of your family, a friend or any other person you identify, your Protected Health Information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose information as necessary if we determine that it is in your best interest based on our professional judgment. We will disclose only health information relevant to the person’s involvement in your care. Examples are allowing another to pick up samples, written prescriptions or allergy extract. We will assume if you bring a spouse or significant other into the exam room with you, treatment and health care issues may be disclosed.

Emergencies: We may disclose your Protected Health Information in an emergency treatment situation. If this happens, your physicians will try to obtain your consent at soon as is reasonably practical after delivery of treatment.

Other Permitted and Required Uses and Disclosures That May be Made Without Your Consent, Authorization or Opportunity to Object”

Required by Law: We will disclose health information when required to do so by Federal, State, or local law enforcement.

Public Health: We may disclose health information to a public health authority to prevent, control disease, injury or disability.

Communicable Diseases: We may disclose health information, if authorized by law, to a person who may have been exposed to a communicable disease, or may be at risk of contracting a spreading disease.

Abuse or Neglect: We may disclose health information to a public authority if we believe there has been child abuse or neglect. We may also disclose health information if we believe that you have been a victim of abuse, neglect, or domestic violence.

Food and Drug Administration: We may disclose health information to a person or company required by the FDA to report adverse event, product defects, or problems, track products, or enable product recall.

Health Oversight: We may disclose health information to a health oversight agency for audits, inspections, investigations, or licensing purposes. These disclosures may be necessary for state and federal agencies to monitor the health care system, government programs, and compliance with civil rights laws.

Legal Proceedings: We may disclose health information in response to any judicial proceeding. Protected Health Information will be released upon a court order, subpoena, or discovery request, or other lawful purpose.

Coroner, Medical Examiners and Funeral Directors: We may disclose health information to the above-named people for identification purposes, determining cause of death, or to be able to perform other duties as authorized by law.

Organ and Tissue Donation: If you are an organ and tissue donor, we may release information to the health organizations that handle these procedures so that such transplantation may be facilitated.

Criminal Activity: We may disclose health information about you if we believe that the disclosure is necessary to prevent a serious threat to the health and safety of you, another person, or the public.

Inmates: We may disclose your health information if you are an inmate of a correctional facility and your physician created or received your Protected Health Information in the course of providing care to you.

Military Activity and National Security: If you a member of the Armed Forces, or National Security Divisions, we may disclose Protected Health Information about you when required by military command or governmental authorities.

Workers Compensation: Your Protected Health Information may be disclosed by us as authorized to comply with workers’ compensation laws and other similar legally-established programs.

Your Rights Regarding Health Information About You:

Right to Inspect and Copy: You have the right to inspect and copy your health information, such as medical and billing records. However, under Federal Law, you may not inspect and copy the following records: psychotherapy notes, information compiled in anticipation or use in a civil, criminal, or administrative action or proceeding. You must submit a written request to the Privacy Officer of this office to inspect or copy your health information. If you request a copy of your record, there will be processing fees for the cost of copying, mailing other associated supplies. If you request to inspect your record, you will be asked to set an appointment time for that inspection to take place. We may deny your request to inspect and/or copy in certain circumstances. If you are denied access, you may ask that the denial be reviewed.

Right to Amend: You may request an amendment to your Protected Health Information as long as we maintain this record in the office. If you wish to make an amendment, you will submit a Medical Record Amendment/Correction Form to the Privacy Officer of this office. We may deny your request if you ask us to amend information that:

  1. We did not create the information that you wish to amend.

  2. The information is not part of the health information that we keep.

  3. You would not be permitted to inspect or copy.

  4. Is accurate and complete.

If we deny your request, you may file a statement of disagreement with us and we may prepare a rebuttal to the same. A copy will be provided to you.

Right to Request Restrictions: You may request a restriction of limitation on health information we disclose about you for treatment, payment, or health care operations. You may also request a limit on the amount of information we may disclose to someone involved in your care. We are not required to agree with your request. If we do agree we will comply with your request unless the information is needed in an emergency situation. If you would like a restriction, you must notify us in writing.

Complaints: You may complain to us or the Secretary of Health and Human Services if you believe that your privacy rights have been violated by us. You may file a complaint with our Privacy Officer at 517.349.0027, or write to Okemos Allergy Center, P.C., 3955 Okemos Rd, Suite A1, Okemos, MI 48864, Attn: Privacy Officer. We will not retaliate for filing such a complaint.

Okemos Allergy Center, P.C.

Privacy Notice Acknowledgement Form

I, (Print Name) ______________________________ acknowledge that I have received a copy of the Privacy Notice of Okemos Allergy Center, P.C..

______________________________________________

Patient Signature (or Legal Guardian, if patient is a minor)

_______________________________________________

Witness Signature

_____________________________

Date

Office Use Only: To be completed if patient refuses to sign acknowledgement

Documentation of Failure to Obtain Signed Acknowledgement

On _________________________(date),

________________________ (Employee Name) presented this

Acknowledgement of Receipt of Privacy Practices to

______________________________(Patient Name).

The patient refused to provide a signature when requested.



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