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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:
dxd
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:
ANTACIDS:
2 Days: Axid, Pepcid, Tagamet, Zantac
Do not need to stop: Prevacid, Prilosec, Nexium DO NOT STOP
ANTI-ANXIETY/DEPRESSANTS:
TAKING YOUR
1 Day: Limbitrol ASTHMA
2 Days: Serequel
3 Days: Elavil (prefer 7 days), Remeron MEDICATIONS
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 Esmolol Propranolol
Atenolol Inderal Rhotral
Betapace Inopran Rythmol
Betaxolol Kerlone Sectral
Bisoprolol Labetalol Sotalol
Blocadren Levatol Tenoretic
Brevibloc Lopressor Tenormin
Carteolol Metoprolol Timolide
Cartrol Monitan Timolol
Carvedilol Nadolol Toprol
Coreg Normodyne Trandate
Corgard Penbutolol Visken
Corzide Pindolol 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:
a. We did not create the information that you wish to amend.
b. The information is not part of the health information that we keep.
c. You would not be permitted to inspect or copy.
d. 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.
