_____________________________ _____________Patient Name

_______________ Date of Birth Patient ID

The providers at Tri-State Allergy use an electronic medical record system that allows electronic prescribing of medications. Prescriptions are sent to your pharmacy through a secure connection (RxHub) which improves the accuracy and timely transmission of your medical information. E-Prescribing greatly reduces medication errors and enhances patient safety. There are several standards that have to be included in an e-prescription program. These include:

Formulary and benefit transactions- Gives the prescriber information about which drugs are covered bythe drug benefit plan.

Medication history transaction- Provides the physician with information about previous and currentmedications the patient is taking to minimize the number of adverse drug reactions.

Fill status notification-Allows the prescriber to receive an electronic notice from the pharmacy tellingthem if the patient's prescription has been picked up or partially filled.

MY SIGNATURE CERTIFIES THAT I HAVE READ AND UNDERSTOOD THE SCOPE OF MY CONSENT AND THAT I AUTHORIZE THE ACCESS OF MY MEDICATION HISTORY.

_____________ _____________________________ _______________________ Patient / Guardian Signature Relationship to Patient Date

Preferred Local Pharmacy Mail‐Order Pharmacy 

Name:   ___________________________ Name:   ___________________________

Street:  ___________________________

City & State:  ___________________________

City & State:  ___________________________

Phone:  ___________________________

eRx Consent 1001 Twentieth Street, Huntington, WV 25703

304-529-6100 Fax: 304-529-0229

Medical Arts Building, 2301 Lexington Avenue Suite 105, Ashland, KY 41101

606-329-0464 Fax: 606-329-1877800-669-6642 / www.tri-stateallergy.com

1001 Twentieth Street, Huntington, WV 25703 304-529-6100 Fax: 304-529-0229

Medical Arts Building, 2301 Lexington Avenue Suite 105, Ashland, KY 41101

606-329-0464 Fax: 606-329-1877_____________________________________________________________________

800-669-6642 / www.tri-stateallergy.com

At this time we would like to WELCOME you to our practice. Thank you for choosing us for your allergy and asthma needs. If you could please fill out the enclosed forms and bring them with you to your appointment it would be very helpful. The allergy history sheets should be filled out in the left column only, leaving the right side of the pages blank for the doctor's notes. All other pages should be filled out as completely as possible with information as it applies to the patient. If you have any questions, please feel free to call our office.

If you cannot keep your appointment, please give us 24 hours’ notice. To cancel or change your appointment please call our main line at 304-529-6100.

PROTOCOL FOR SKIN TESTING Must be stopped for 4 days before testing: Must be stopped for 7 days before testing: Medications: Claritin, Allegra, Atarax, Tylenol Sinus/PM,

Cough syrups, Cold medicines, Optimine, Loratadine, Zyrtec, Marax, Alavert, Cetirizine, Periatin, Sleep aids, Phenergan, Xyzal, Fexofenadine, Benadryl, Vistaril, Tussionex, Stahist, Semprex

Clarinex

Nasal Sprays: Astelin, Astepro, Patanase, Dymista Eye drops: Pataday, Patanol, Optivar, Zaditor, Elestat

Please avoid some anti-depressants and anti-nausea medications for 4 days prior to your testing appointment. (Prozac, Paxil, Wellbutrin and Serzone as well as some other antidepressants are fine to use and do not need to be stopped). Please call and check with our nurse if you are unsure about any prescriptions you may be taking.

Please bring your medical records, including, X-ray and CT scan reports, which may be obtained from your referring doctor or family doctor.

EXPLANATION OF SKIN TESTING PROCEDURES Skin testing involves placing up to 116 drops of liquid on the patient's back, then lightly pricking the drops. The patient must lie still for 15 - 20 minutes. These drops may itch, but it is important that the patient not move or scratch, after about 15 minutes, the doctor will read the results. Not all young children can have this type of testing, as they are unable to lie still long enough. The second part of the test involves up to 30 intradermal injections on the inner aspect of the forearms. This test is also read by the doctor after 15-20 minutes. It is permissible to move your arms after this testing, but do not touch or scratch the testing surface. A numbing patch is available for young children for a charge of $30.00, which must be paid for at the time of the visit. In order to have this patch applied, you should come to the office half an hour before your scheduled appointment.

Please note there may be a non-cancellation fee of $50.00 charged if appointment is NOT canceled within 24 hours of your scheduled time.

Thank you for your cooperation in helping us expedite your visit

Acknowledgement: Receipt of Notice of Privacy Practices

1001 Tw entieth Street, Huntington, WV 25703

304-529-6100 Fax: 304-529-0229

Medical Arts Building, 2301 Lexington Avenue

Suite 105, Ashland, KY 41101

606-329-0464 Fax: 606-329-1877

_____________________________________________________________________

800-669-6642 / w ww.tri-stateallergy.com

_____________________________ ______________ _____________ Patient Name Date of Birth Patient ID

TRI-STATE ALLERGY, INC. reserves the right to modify the privacy practices outlined in the notice.

I acknowledge that I have been provided Tri-State Allergy Inc.’s HIPAA Notice of Privacy Practices

(“Notice”):

It tells me how Tri-State Allergy will use my health information for the purposes of my

treatment, payment for my treatment, and Tri-State Allergy’s health care operations.

The Notice explains in more detail how Tri-State Allergy, Inc. may use and share my health

information for other than treatment, payment, and health care operations.

Tri-State Allergy, Inc. will also use and share my health information as required/permitted by

law.

Signature:

_____________ _____________________________ _______________________ Patient / Guardian Signature Relationship to Patient Date

Patient Registration Adult

Patient ID:__________

First Name Last Name Middle

Date of Birth Social Security # Marital Status

Single Married Widowed

Physical Address

City State & Zip

Mailing Address

City State & Zip

Home Phone: Mobile Phone: E-mail:

Female

Male

Race

American Indian African American

Asian Native Hawaiian

White

Ethnicity

Hispanic or Latino

Non Hispanic or Latino

Employer Information Work Phone

Employer Position

Address City State & Zip Length of Employment

Emergency Contact Information

Contact Relationship Home Phone Mobile Phone

Contact Relationship Home Phone Mobile Phone

Spouse Information

First Name Last Name Middle

Date of Birth Social Security #same address?

Physical Address

City State & Zip

Mailing Address

City State & Zip

Home Phone: Mobile Phone: E-mail:

Employer Information Work Phone

Employer Position

Address City State & Zip Length of Employment

Assignment and release of information (please place initial at each line)

_____ I, the undersigned certify that I have insurance coverage and assign directly to Tri-State Allergy, Inc, and it's physicians all Medicaid, Medicare, and Insurance benefits for services rendered to me.

_____ I understand that I am responsible for the balance of my bill if payment has not been received within 90 days of services rendered.

_____ AUTHORIZATION TO RELEASE MEDICAL INFORMATION: I hereby authorize the release of any and all medical records acquired in the course of my examination or treatment necessary to establish a health insurance claim.

_____ TREATMENT AUTHORIZATION: I hereby authorize medical treatment as the Tri-State Allergy, Inc physician(s) deems necessary.

______________________________________ ____________________ Signature Date

Insurance Policyholder Information

First Name Last Name Middle

Date of Birth Social Security #same address?

Physical Address

City State & Zip

Mailing Address

City State & Zip

Home Phone: Mobile Phone: E-mail:

Work PhoneEmployer Information

Employer

Address City

Position

State & Zip Length of Employment

______________________________________ Signature

____________________ Date

Insurance Company Name

ID#

(Red Boxes are Required Information)

Payment Policy 1001 Twentieth Street, Huntington, WV 25703

304-529-6100 Fax: 304-529-0229

Medical Arts Building, 2301 Lexington Avenue Suite 105, Ashland, KY 41101

606-329-0464 Fax: 606-329-1877800-669-6642 / www.tri-stateallergy.com

Patient ID: ____________

Thank you for choosing Tri-State Allergy, Inc. as your health center for allergies and immunology.

Due to the expense of allergy testing and treatment, you will be asked to make a deposit at the time of your initial workup and office visit. We ask new patients to be prepared to pay their co-payment and un-met deductible on their initial visit. You may request a payment plan, however you will need to pay any deductible, co-pay or coinsurance on the day of your appointment. Patients with a set co-pay will be required to make the co-payment PRIOR to services being rendered.

We do accept most major credit cards, checks and cash as payment. Payment to patient's accounts MUST NOT be withheld or delayed due to pending insurance coverage on claims. As a courtesy to all our patients, we will bill your insurance for you. However, final responsibility for the bill remains with the patient, or the Parent of a minor patient.

While every attempt will be made to resolve any outstanding balances, please be aware, if legal action becomes necessary to collect monies owed, all proceedings will be brought in the county in which the services were rendered.

I have read, understand and will comply with the above.

(Patient or Responsible Party)Signature ________________________________________ Date ____________

For your convenience please fill out information below for easy monthly payment and specific date you would like to have account drafted.

Card # Expiration Date:

Card Type:

American Express MasterCard Visa Discover

Signature: __________________________ Draft Date: _________________