ALL FORMS CONTAINED IN THIS BUNDLE MUST BE COMPLETED FOR ALL PATIENTS BEING SEEN AT ALLERGY AND ASTHMA INSTITUTE OF SE MICHIGAN.

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Patient Registration

Gender

Primary Insurance

Do you have insurance?

Please be aware that payment will be required on the date of service.

Social Security Number is often needed to verify insurance coverage and without this information we may not be able to fully verify your benefits. Data collected here will be transferred via a secure HIPAA compliant platform.

Secondary Insurance

Primary Care Physician or Pediatrician

Pharmacy

Emergency Contact

You will be required to provide additional information at your first appointment including physical copies of your drivers license or state id as well as your insurance card.

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Acknowledgement Form for Purposes of Treatment, Payment and Healthcare Operations

I acknowledge the use or disclosure of my protected health information by Allergy and Asthma Institute of SE MI of diagnosing or providing treatment to me, obtaining payment for my healthcare bills or to conduct healthcare operations of Allergy and Asthma Institute of SE MI. I understand that diagnosis or treatment of me by the physicians of Allergy and Asthma Institute of SE MI may be conditioned upon my consent as evidenced by my signature on this document.

I understand I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment, or healthcare operations of the practice. Allergy and Asthma Institute of SE MI is not required to agree to the restrictions that I may request. However, if Allergy and Asthma Institute of SE MI agrees to a restriction that I request, the restriction is binding on Allergy and Asthma Institute of Southeast MI and physicians of Allergy and Asthma Institute of SE MI. I have the right to revoke this consent, in writing, at any time, except to the extent that physicians of Allergy and Asthma Institute of SE MI has taken action in reliance on this consent.

My “protected health information” means health information, including my demographic information, collected from me, and created or received by my physician, another healthcare provider, a health plan, my employer, or a healthcare clearinghouse. This protected health information relates to my past, present or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me.

I understand I have a right to review Allergy and Asthma Institute of SE MI Notice of Privacy Practices prior to signing this document. The Allergy and Asthma Institute of SE MI Notice of Privacy Practices has been provided to me. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of healthcare operations of the Allergy and Asthma Institute of SE MI. The Notice of Privacy Practices for Allergy and Asthma Institute of SE MI is also provided in patient reception area. This Notice of Privacy Practices also describes my rights and Allergy and Asthma Institute of SE MI duties with respect to my protected health information.

Allergy and Asthma Institute of SE MI reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of privacy practices by reviewing the notices provided in patient reception area or by calling the office and requesting a revised copy be sent in the mail or asking for one at the time of my next appointment.

Authorization and Consent for Treatment

The undersigned agrees, whether they sign as agent or as a patient, that in consideration of agreed upon services to be rendered, including allergy extracts and injections, by the Allergy and Asthma Institute of SE MI to the patient, they hereby obligate themselves, assumes financial responsibility, and agrees to pay upon request to provider all charges for such services incurred by said patient. All deductibles, co-payments and co-insurance are due at the time of service. Should the account be referred to an attorney/collection agency for collection, the undersigned shall pay all responsible attorney fees and collection expenses, including any reasonable attorney fees and reasonable collection agency fees not to exceed 30%. The undersigned consents to treatment as determined and discussed with and agrees to medication history review and reconciliation. The undersigned understands that all bills are payable upon presentation and that they, not the insurance company, is responsible for the payment of the services. This office will file and collect from insurance when insurance benefits are present. All balances beyond the contracted insurance rates are payable by the patient due on receipt of a patient statement in the mail. I hereby authorize Allergy and Asthma Institute of SE MI to use “Signature on File” in lieu of an original signature for all medical claims submitted for services rendered to patient. I acknowledge that all information regarding my identity is correct and accurate to my knowledge. By signing this document, I understand that I am held accountable for any false information which could result in a fine or penalty and should notify the Allergy and Asthma Institute of SE MI if any of my information should change or if my identity is compromised or stolen.

Payment Policy

Thank you for choosing our practice. We are committed to providing you with quality and affordable healthcare. Below is information to answer frequently asked questions regarding patient and insurance responsibility for services rendered. Please read it, ask us any questions that you may have and sign in the space provided. A copy will be provided to you upon request. Thanks so much for being our patient.

ALL COPAYS ARE DUE AT THE TIME OF SERVICE UNLESS PAYMENT ARRANGEMENTS HAVE BEEN REQUESTED AND APPROVED IN ADVANCE BY THE PRACTICE MANAGER OR OFFICE MANAGER. IF AN ARRANGEMNT HAS BEEN MADE YOU ARE EXPECTED TO PAY ACCORDING TO THAT ARRANGMENT.

Insurance: We participate with most insurance plans. We will bill your insurance company as a courtesy to you. We may be able to estimate what your insurance company may pay; it is the insurance company that makes the final determination of your eligibility as well as what portion of the service you are responsible for.

Claims Submission: Billing will submit your claims and assist you in any way we reasonably can to help you get your claims paid. Your insurance company may need you to supply certain information directly to them. It is your responsibility to comply with their request(s). Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company.

Referrals: If you have an insurance plan with which we are contracted you may still need a referral authorization from your primary care physician/pediatrician. It is your responsibility to understand your insurance and if such a referral is required by them for you to be seen in our office. If we have not received a referral at least 48 hours prior to your appointment your appointment will be rescheduled. If you are seen without a referral or have an expired referral, we will do our best to work with our billing company to resubmit your visit once you have an active referral, but some insurance carriers will not pay for visits retroactively. If a visit is denied by your insurance company, you will be responsible for any uncovered charges.

Co-payments: All co-payments are to be paid at the time of service. This arrangement is part of your contract with your insurance company.

Proof of Insurance: All patients must complete our entire new patient paperwork package prior to being see in our office for the first time. In addition, we must obtain a copy of your driver’s license or state issued identification card as well as your insurance card(s). If you fail to provide us with correct insurance information in a timely manner you may be responsible for the balance of the claim(s).

Coverage Changes: If your insurance changes please notify us before your next visit so we can update your information to help you receive your maximum benefits.

Methods of Payment: We accept payment by cash, check, Visa, Mastercard or American Express.

Patient Statements: Any account with an unpaid balance will receive statements either by mail or electronically. Balances over 90 days old may be routed to our tier one balance collection service. Balances over 120 days old may be turned over to a collection service. All payments made will go to the oldest outstanding balance.

Appointment Confirmations / No Show Fees: Our office utilizes appointment confirmation software that will contact you prior to your appointment either via email, text/sms or a phone message. A response is required to appointment confirmation messages as this allows our office to staff accordingly and provide patient safety. Standard office visits and up doses require 24-hour cancellation notice. Procedure appointments such as Day 1, Challenges and Rapid Desensitization require a 10-day cancellation notice. We have a wait list for procedure appointments and the extended cancelation notice allows our office to offer those appointments to other patients. At our discretion, a fee equal to the cost of your appointment will be charged. In addition, if the appointment missed was a scheduled procedure your deposit may not be refunded or applied to a future scheduled procedure.

Collection Fees: Balances that have not had a payment made within 120 days and are turned over to a collection service will be increased by 30% to cover attorney fees or collection fees. The guarantor is responsible for these fees in addition to their balance.

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.
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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.
PLEASE REVIEW IT CAREFULLY.

Uses and Disclosures: The following categories describe different ways that we use and disclose medical information. For each category of uses or disclosures, we will elaborate on the meaning and provide more specific examples, if you request. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories. We must obtain your authorization before the use and disclosure of any psychotherapy notes, uses and disclosures of PHI for marketing purposes, and disclosure that constitute a sale of PHI. Uses and disclosures not described in this Notice of Privacy Practices will be made only with authorization from the individual.

For Payment: We may use and disclose medical information about you so that the treatment and services you receive at the Practice may be billed to and payment may be collected from you, an insurance company or a third party. For example: we may disclose your record to an insurance company, so that we can get paid for treating you.

For Treatment: We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other personnel who are involved in taking care of you at the Practice or the hospital. For example, we may disclose medical information about you to people outside the Practice who may be involved in your medical care, such as family members, clergy or other persons that are part of your care.

For Health Care Operations: We may use and disclose medical information about you for health care operations. These uses and disclosures are necessary to run the Practice and ensure that all of our patients receive quality care. We may also disclose information to doctors, nurses, technicians, medical students, and other Practice personnel for review and learning purposes. For example, we may review your record to assist our quality improvement efforts. WHO WILL FOLLOW THIS NOTICE. This notice describes our Practice's policies and procedures and that of any health care professional authorized to enter information into your medical chart, any member of a volunteer group which we allow to help you, as well as all employees, staff, and other Practice personnel.

Other Permitted and Required uses and Disclosures That May be Made Without Your Authorization or Opportunity to Agree or Object

We may use or disclose your protected health information in the following situations without your authorization or providing you the opportunity to agree or object. These situations include:

Required By Law: We may use or disclose your protected health information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, if required by law, of any such uses or disclosures.

Public Health: We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. For example, a disclosure may be made for the purpose of preventing or controlling disease, injury, or disability.

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

Health Oversight: We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.

Abuse or Neglect: We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclose will be made consistent with the requirements of the applicable federal and state laws.

Food and Drug Administrations: We may disclose your protected health information to a person or company required by the Food and Drug Administration for the purpose of quality, safety, or effectiveness of FDA-regulated products or activities including, to report adverse events, product defects or problems, biologic product defects, to track products: to enable product recalls, to make repairs or replacements, or to conduct post marketing surveillance, as required.

Legal Proceedings: We may disclose your protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), or in certain conditions in response to a subpoena, discovery request or other lawful process.

Law Enforcement: We may also disclose protected health information, so long as the applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of our practice, and (6) medical emergency (not on our practice’s premises) and it is likely that a crime has occurred.

Coroners, Funeral Directors, and Organ Donation: We may disclose your protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipate of death. Protected health information may be used and disclosed for cadaveric organ, eye, or tissue donation purposes.

Research: We may disclose your protected health information to researching when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols that ensure the privacy of your protected health information.

Criminal Activity: Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use of disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual.

Military Activity and National Security: When the appropriate conditions apply, may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities, (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities including for the provisions of protective services to the president or others legally authorized.

Workers’ Compensation: We may disclose your protected health information as authorized to comply with workers’ compensation laws and other similar legally established programs.

Inmates: We may disclose your protected 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 provided care to you.

OTHER USES OF MEDICAL INFORMATION: Other uses and disclosures of medical information not covered by this notice or the laws that apply to use will be made only with your written authorization. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time.

POLICY REGARDING THE PROTECTION OF PERSONAL INFORMATION: We create a record of the care and services you receive at the Practice. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by the Practice, whether made by Practice personnel or by your personal doctor. The law requires us to: make sure that medical information that identifies you is kept private; give you this notice of our legal duties and privacy practices with respect to medical information about you; and to follow the terms of the notice that is currently in effect. Other ways we may use or disclose your protected healthcare information include appointment reminders; as required by law; for health-related benefits and services; to individuals involved in your care or payment for your care; research; to avert a serious threat to health or safety; and for treatment alternatives. Other uses and disclosures of your personal information could include disclosure to, or for: coroners, medical examiners, and funeral directors; health oversight activities; law enforcement; lawsuits and disputes; military and veterans; national security and intelligence activities; organ and tissue donation; public health risks; and worker's compensation.

NOTICE OF INDIVIDUAL RIGHTS

You have the following rights regarding medical information we maintain about you:

Right to a Paper Copy of this Notice: You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time.

Right to Inspect and Copy: You have the right to inspect and copy medical information that may be used to make decisions about your care. We may deny your request to inspect and copy in certain very limited circumstances.

Right to Amend: If you feel that medical information, we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by, or for, the Practice. To request an amendment, your request must be made in writing and submitted to the Privacy Officer and you must provide a reason that supports your request. We may deny your request for an amendment.

Right to Request Restrictions: You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions, you must make your request in writing to the Privacy Officer.

Right to Request Removal from Fundraising Communications: You have the right to opt out of receiving fundraising communications from the Practice.

Right to Restrict Disclosures to Health Plan: You have the right to restrict disclosures of PHI to a health plan if the disclosure is for payment of health care operations and pertains to a health care item or service for which the individual has paid out of pocket in full.

Right to Request Confidential Communications: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. You must make your request in writing and you must specify how or where you wish to be contacted.

Right to an Accounting of Disclosures: You have the right to request an "accounting of disclosures." This is a list of the disclosures we made of medical information about you. To request this list or accounting of disclosures, you must submit your request in writing to the Privacy Officer. CHANGES TO THIS NOTICE. We reserve the right to change this notice. We will post a copy of the current notice in the Practice's waiting room.

COMPLAINTS: You may complain to us or to the Secretary of Health and Human services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our Privacy Office of your complaint. You will not be penalized for filing a complaint.

U.S. Department of Health and Human Services
HIPAA Complaint
7500 Security Blvd., C5-24-04
Baltimore, MD 21244

You may contact our Privacy Officer, Lisa Mayer at (248) 363-3232 for further information about the complaint process.

This notice was published and becomes effective on April 15, 2021

We may change our policies and this notice at any time and have those revised policies apply to all protected health information we maintain. If or when we change our notice, we will post the new notice in the office where it can be reviewed.

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.
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Procedure Payment Policy & Missed Appointment Fees

Procedures include: Oral Immunotherapy Day One, Oral Challenge, Rapid Desensitization or Food or Drug Testing.

Thank you for choosing our practice. We are committed to providing you with quality and affordable healthcare. Patients often have questions regarding patient and insurance responsibility for services rendered. To help answer these questions we have outlined our polices in this document. Please review, ask us any questions you may have and then sign as outlined. A copy of this document can be provided upon request.

To schedule an appointment for any of the above-mentioned services a credit card on file is required. For your security, all credit card details will be stored in an encrypted platform.

Insurance

We participate with most insurance plans. We will bill your insurance company for services rendered. Depending on your insurance plan we may be able to provide you with an estimate of what your benefits may cover but ultimately your insurance company makes the final determination of your eligibility.

Claims Submission

We will submit your claim and assist you in any way we reasonably can to help get your claim(s) paid. On occasion insurance companies may require you to submit certain information to them directly, it is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Please remember your insurance benefit is a contract between you and your insurance company.

Referrals

If your insurance plan with which we are contracted requires a referral authorization from your primary care physician or pediatrician you will need to obtain the referral prior to your visit at Allergy & Asthma Institute of SE MI, PLLC. If we do not have a referral on hand at the time of your appointment your appointment will need to be rescheduled.

Proof of Insurance

All patients must complete our patient information form in its completion prior to seeing our providers. We MUST obtain a copy of your driver’s license or state issued ID and a valid insurance card. If you fail to provide correct insurance information in a timely manner, you may be responsible for charges associated with your visit.

Coverage Changes

If your insurance changes please notify us prior to your next visit so we can make the appropriate changes to help you receive your maximum benefits.

Payment Methods

We accept cash, check, Visa, Mastercard and American Express.

Statements

If you have an unpaid balance you will receive at the very least one statement per month. The statement amount is due and payable when the statement is issued. The exception to this would be for the Oral Immunotherapy program. The day one services are expected to be paid in full within three months and all other visits in the program are due as statements are received. If you require a modified payment plan for the Oral Immunotherapy program, please contact our practice manager Lisa Mayer, via email at Lmayer@theallergydoc.com or by phone 248-468-1575. We would also ask if you do not receiving statements please let us know so we can confirm your address to ensure you receive notification of amounts due in a timely manner.

Procedure Appointment Cancellation Policy

In the event that you or your child are unable to attend your appointment please contact our patient engagement staff at 248-363-3232 10 days prior to your scheduled appointment to avoid incurring the cancelation fee.

Oral Challenge, Rapid Desensitization and Food or Drug Testing charge of $250.00 may be charged to the credit card on file for insufficient cancelation notice.

Oral Immunotherapy Day One a charge of $500.00 may be charged to the credit card on file for insufficient cancelation notice.

Missed Appointment Fees

Allergy & Asthma Institute of SE MI, PLLC utilizes appointment confirmation software. You will receive a notice prior to your appointment either via text/sms, voice message or email. Each of these methods requires a response. If you do not respond either confirming or cancelling your appointment and you miss your appointment you may be charged a missed appointment fee. If you respond confirming your appointment and subsequently miss that appointment you will be charged a missed appointment fee. A history of multiple missed appointments may result in discharge from the practice.

The missed appointment fee is $125.00.

Please understand that we build our schedule and staff based on patient needs. When we schedule and staff for procedures and appointments the associated internal costs remain the same when appointments are missed. Without ample notice we are not able to offer schedule openings to the patients on our appointment wait list. Charges associated with insufficient notice for cancellation or missed appointments are not a source of revenue but overhead management.

I have read and understand Allergy & Asthma Institute of SE MI, PLLC procedure payment and missed appointment policies and I agree to abide by these standards. I understand I agree to pay and charge not covered by my insurance company. I understand my credit card on file will be charged in relationship to procedures and that missed appointment fees will be reflected on my statements.

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.
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Acknowledgement of Privacy Practices & Financial Agreement Form

Acknowledgement of Receipt of Notice of Privacy Practices

I acknowledge receiving a copy of the Allergy & Asthma Institute of SE MI, PLLC, Notice of Privacy Practices.

** Authorized representatives include: Legal Guardian, Emancipated Minor or Patients between ages 14-18 seen for conditions not requiring parental consent.

Acknowledgement of Payment Authorization & Financial Agreement

This is an acknowledgement of release of information, benefit assignment, payment authorization, full disclosure statement and agreement to pay for professional services.

I,

(print name of person completing this form), authorize Allergy & Asthma Institute of SE MI, PLLC, to release an information acquired during the course of my examination or treatment to my insurance company for the purposes of processing my insurance/medical claim. In agree to allow a photocopy of my signature to be used to process my insurance/medical claim for the period of lifetime. I claim any insurance benefits due to me for services rendered by Allergy & Asthma Institute of SE MI, PLLC and authorize and assign payment directly to Allergy & Asthma Institute of SE MI, PLLC, regardless of my insurance benefits. I agree to promptly pay for the services rendered for me or the patient named above. If I fail to meet my financial commitment to Allergy & Asthma Institute of SE MI, PLLC and it becomes necessary to take action to collect my account, I agree to pay all costs and expenses incurred in the collection of my account, including attorney and collection agency fees (not to exceed amounts allowable in the state of Michigan).

All past due balances over 120 days may be sent to a collection agency and the responsible party is liable for any charges and legal fees incurred by our office as a result of this action (not to exceed amounts allowable in the state of Michigan).

I have fully disclosed all information concerning the insurance/third party benefits to which I am entitled. I understand that failure to disclose pre-certified /second opinion requirements for any and all plans to which I subscribe may cause me to incur full liability for professional charges as a result of nonpayment by any carrier.

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Email Consent Form

The practice of Allergy & Asthma Institute of SE Michigan, PLLC offers patients the benefit of communication via e -mail. In addition to personal and telephone discussions, we would like to use e-mail as a method of communication with the Practice and have read and understand the following:

Privacy

I understand that e-mail may be used only for non-emergency questions and requests in the ordinary course of business and, as a result, persons employed by the practice will be responsible for access to and processing such communications. I understand that confidential and sensitive information will never be shared with a third party without my written authorization. I also understand that there are certain situations in which Allergy & Asthma Institute of SE Michigan may share my e-mail messages without written authorization (e.g., disclosures required by state or federal law). I also understand that if law requires a disclosure, only the minimum amount of information necessary to achieve the purpose of the request will be disclosed. Subsequently, I will receive notice that the disclosure was made.

Response Time

The Practice will make every effort to respond to your e-mail request within 1-2 business days. If, for any reason (such as vacation, illness, emergency), we are unavailable to answer your e-mail request within the designated timeframe, you will receive a response from another physician or employee from the practice authorized to address your e-mail. Users will receive an automatic reply message from the practice to confirm receipts of an e-mail message. The message will state the expected office response time and include contact information if you need immediate assistance.

Permissible Uses

The Practice will allow e-mail use for medical advice and non-urgent or non-emergency matters including appointments, prescription refills, billing/insurance questions and non-emergency advice.

Non-Permissible Uses

Prohibited uses of e-mail include but are not limited to 1) Urgent or time-sensitive communications 2) Highly confidential or sensitive information, e.g., discussion of HIV status, mental illness, chemical dependency, and workers compensation claims 3) Using e-mail to attach large database files or files containing inappropriate materials unrelated to the permissible uses defined above. If the practice feels the content or subject matter of an e-mail is inappropriate for an electronic response, it reserves the right to refuse communication via e -mail and will suggest alternate means to discuss the question or request. I understand that at no time should I expect a diagnosis, a recommendation of treatment or a prognosis via e-mail regarding a complaint or symptom for which the physician did not see me personally, regardless of whether the physician has seen me personally on prior occasions. I understand that at any time the Practice may terminate e-mail communications with me and that I will be notified of such termination by a written letter. I understand that termination of online communication does not necessarily mean termination of the patient-physician relationship.

Patient Responsibilities

I understand that e-mail should be used only for appropriate messages and non-urgent situations. I agree to call the practice immediately if the situation escalates to a point where a phone call or visit is necessary. I also agree to do the following when making an email request:

  1. Choose the category of the transaction offered (e.g., prescription, appointment, medical advice, billing question).
  2. Place my full name and patient ID in the first line of the body of the message.
  3. Configure automatic reply to acknowledge receipt of the message, if possible.

I also understand that all messages, with replies and confirmation of receipt will be printed and placed in the patient’s medical record, and it is the patient’s duty to maintain their own copies of e-mail communications.

Security

The Practice has the following security mechanisms in place to secure confidential and sensitive information:

  1. Encryption will be used for all messages when practical and always for confidential or private information.
  2. Back-ups of data will be performed monthly onto a long-term storage.
  3. Password protection allows access only to authorized users permitted to access and handle all office e-mail communications.
  4. Password protected screen savers will be used on computers, including keeping all screens out of public view. 5) Information sent in a group mailing will maintain the confidentiality of the patient by using a blind copy to keep recipients invisible to each other.

Indemnification

You agree to indemnify, defend, and hold harmless Allergy & Asthma Institute of SE Michigan, PLLC, its officers, directors, employees, agents, and independent contractors from and against any and all losses, expenses, damages and costs arising out of your use of Patient e-mail, any activity related to your patient account information and any information lost due to technical failures.

Consent

I have read this consent and have been given the opportunity to discuss the issues with the practice and understand that by signing this consent I agree to the above policy and conditions established by this practice. I understand that I may also withdraw consent for the use of e-mail interactions at any time without affecting my right to future treatment.

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Informed Consent for Telemedicine Services Form

Telemedicine involves the use of various electronic communications to enable the staff at Allergy and Asthma Institute of Southeast Michigan to provide off site patient care. Electronic systems used will incorporate network and software security protocols to protect the confidentiality of the patient identification and data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

  1. I authorize and voluntarily consent to the participation and treatment of myself or child in a telemedicine visit with Allergy and Asthma Institute of Southeast Michigan.
  2. I understand that as a participating patient, my physician and I will communicate by a secure platform and that phone-based participation may be needed during the visit.
  3. It has been explained to me how telemedicine through an online video platform will be used to conduct a visit. I understand that this visit will not be the same as an in-person visit due to the fact that I or my child will not be in the same room as the healthcare provider at the Allergy and Asthma Institute of Southeast Michigan. I also understand that I have the option to see the provider in person if I chose.
  4. Allergy and Asthma Institute of Southeast Michigan has provided me with a list of supplies that I commit to having readily available to me at the beginning and throughout my entire telemedicine visit (applicable to oral immunotherapy visits only). I understand that if I do not have these items ready and available to me at the start of my telemedicine visit that the visit may need to be cancelled, rescheduled and that visit charges may apply.
  5. I further understand that there are potential risks to telemedicine, including but not limited to, interruptions, unauthorized access, and technical difficulties. I understand that either the healthcare provider or I can discontinue my child’s telemedicine health visit if it is felt that the video conferencing connections are not adequate for the situation.
  6. I understand that it may be necessary to have several staff members involved in the telemedicine process just like any in person visit with Allergy and Asthma Institute of Southeast Michigan. I further understand that the individuals present are bound to maintain confidentiality of all information obtained.
  7. During the telemedicine visit, I understand that the responsibility of the telemedicine healthcare provider concludes upon termination of the video conference connection and that Allergy and Asthma Institute of Southeast Michigan is not responsible for actions at the distant site. I further understand scheduled monitoring of the visit via phone will be conducted at predetermined intervals with a visit conclusion via active video conferencing feed (applicable to oral immunotherapy visits only).
  8. I understand that the charges associated with telemedicine visits if not covered by insurance plan either in full or partially are the responsibility of the guarantor listed above. I understand that prompt payment for telemedicine visits if not covered in full or partially is expected.
  9. I understand that I have the right to withdraw my consent in relationship to telemedicine visits at any time.

I have read and understand the information provided above regarding telemedicine, I have discussed it with my physician or other medical staff team members at Allergy and Asthma Institute of Southeast Michigan, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telemedicine in my medical care.

I hereby authorize Allergy and Asthma Institute of Southeast Michigan to use telemedicine in the course of my diagnosis and/or treatment wherever deemed suitable.

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Contact Preferences for Automated Appointment Confirmation and Patient Portal Form

Automated Appointment Confirmation

Our practice utilizes an automated appointment confirmation process. You have an option available to you in the process. Please select one contact preference and provide the information necessary to support that preference (as shown below). We can only activate one option and messages can only be sent to one number.

There is no charge by AAISEMI to provide this service however your carrier of choice may charge for SMS messages based on your specific plan.

Patient Portal

We utilize a patient portal to communicate with patients. This will give you access to practice information such as details on our services. You will also have specific appointment information, messaging and correspondence with staff and billing details/payments.

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COVID-19 Risk Informed Consent Form

I,

(patient/guardian name) understand that I am opting for a non-urgent appointment at the Allergy & Asthma Institute of SE Michigan. I understand that the novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. I further understand that COVID -19 is extremely contagious and is believed to spread by person-to-person contact; and as a result, federal and state health agencies recommend social distancing. I recognize that the staff at Allergy & Asthma Institute of SE Michigan are closely monitoring this situation and have put in place reasonable preventive measures aimed to reduce the spread of COVID -19. However, given the nature of the virus, I understand there is an inherent risk of becoming infected with COIVD-19 by the virtue of proceeding with this non-urgent appointment. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this non-urgent appointment.

I understand that possible exposure to COVID -19 before/during/after my appointment may result in the following: a positive COVID -19 diagnosis, extended quarantine/self-isolation, additional tests, hospitalization that may require medical therapy, Intensive Care treatment, possible need for intubation/ventilator support, short term or long-term intubation, other potential complications, and the risk of death.

I understand that COVID -19 may cause additional risks, some or many of which may not currently be known at this time in additional to the risks described herein.

I have been given the option to defer my appointment to a later date or to schedule a telemed visit if applicable. However, I understand all the potential risks, including but not limited to the potential short-term and long-term complications related to COVID -19, and I would like to proceed with my appointment.

I UNDERSTAND THE EXPLANATION AND HAVE NO MORE QUESTIONS AND AGREE TO PROCEED WITH MY APPOINTMENT. I UNDERSTAND THIS CONSENT WILL APPLY TO ALL FUTURE APPOINTMENTS.

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We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

Continue