New patient cancellation policy

Allergy Diagnostic and Treatment Center • David K. Brown, MD
Christian D. Gonzoph, PA-C • Rebecca A. Rosenberger, PA-C • Kristine M. Cisko, PA-C
33 Overlook Road, Suite # 307, Summit, NJ 07901
Tel . (908) 522-9696/Fax: (908) 522-3070
New Patient Cancellation Policy
Welcome to our practice and thank you for choosing us! We appreciate your confidence and goodwill. Your appointment will take approximately 2 hours. • Please be aware that a there is a last minute cancellation charge of $225.00. Patients must
give at least 24 hours notice; please call 908-522-9696. The fee of $225.00 can be credited back to your account if you actually proceed with a new patient consultation. • Patients who are 15 (or more) minutes late may have to rescheduled their appointments.
Patient Instructions for New Patients/Skin Testing
3 days or 72 hours before your testing appointment please stop taking the following medications:
• Antihistamines, Decongestant/antihistamine combination medications, see list below
• Astelin, a prescription nose spray antihistamine
• Any over the counter allergy medicines, cold & cough remedies
• Any over the counter sleep aids, they usually contain a sedating antihistamine
• Vitamin C, if you are taking 1000 mg or more: large doses act as a natural antihistamine
Please review these lists of medications. If you are not certain if you are taking a product that contains an antihistamine, ask your pharmacist or call this office. Contain antihistamines
Decongestant/Antihistamine combinations
Actifed (Triprolidine)
Allegra D
Claritin D
Allegra (Fexofenadine)
Naldecon
Antivert or Bonine (Meclizine)
Polyhistine D
Astelin (dispensed as a Nose Spray)
Atarax (Hydroxyzine)
Benadryl (Diphenhydramine)
Trinalin Repetabs
Bromfed (Brompheneramine)
Chlortrimeton (Chlorpheniramine
Claritin (Loratidine) or Clarinex
Most over the counter cold, cough medications
Dramamine (Dimenhydrinate)
PBZ (Tripelenamine)
Periactin (Cyproheptadin)
Phenergan (Promethazine)
Polyhistine (Phenyltoloxamine)
Semprex (Acrivastine)
Tavist (Clemastine)
Tylenol PM
Unisom (Doxylamine)
Zyrtec (Cetirizine)
You should continue to take as prescribed the following medications: • Antibiotics
• All asthma medications
• Prescription nose sprays, with the exception of Astelin, which is an antihistamine
• Decongestants that are not combined with an antihistamine

Please dress accordingly: the first phase of testing (prick tests) are done on the forearm and the second
phase of testing (intradermal tests) are done on the upper arms.
Allergy Diagnostic and Treatment Center • David K. Brown, MD
Christian D. Gonzoph, PA-C • Rebecca A. Rosenberger, PA-C • Kristine M. Cisko, PA-C
33 Overlook Road, Suite # 307, Summit, NJ 07901
Tel . (908) 522-9696/Fax: (908) 522-3070
Patient Information
Patient Name __________________________________ Home Phone: ( ) ________________ Patient SS # ________-________-__________
Mailing Address: _________________________________ Cell Phone: ( ) ________________ City: _____________________________
Email: ________________________________________________________________________
Sex: □ Male □ Female
Who may we thank for referring you? _____________________________________________ In Case Of An Emergency, Contact: ____________________________ Phone: ( ) _____________ Insurance Information
All co-pays and self-pay services (SLIT& medical supplies) are expected to be paid the day of service
Primary care MD:________________________________

Primary Insurance Company
Secondary Insurance Company
Subscriber:______________________________
Date of Birth:________________________
Date of Birth: ___________________________

Social Security # _____________________
Social Security # _________________________
ID# ______________ Group # _____________ Copay $ __________ Co-Ins $ _____________ Assignment And Release
I, the Undersigned, have my insurance with ___________________________________________________
and assign directly to the Allergy Diagnostic And Treatment Center all medical benefits, if any, otherwise
payable to me for services rendered. I understand that I am financially responsible for all charges whether or not
paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of
benefits. I authorize the use of this signature on all my insurance submissions.
______________________________________________
Signature
Allergy Diagnostic and Treatment Center • David K. Brown, MD
Christian D. Gonzoph, PA-C • Rebecca A. Rosenberger, PA-C • Kristine M. Cisko, PA-C
33 Overlook Road, Suite # 307, Summit, NJ 07901
Tel . (908) 522-9696/Fax: (908) 522-3070
Financial Policy
In an effort to provide the best allergy specialty care at the lowest possible cost to you, our financial
policy is designed to clearly define your responsibility for payment and our role in assisting you with
insurance reimbursement for services you receive. We participate in most insurance plans, and bill to
primary and secondary insurances. If you have any questions about our participation, please contact your
insurance company or call our office. If we do not have a contractual agreement with your insurance
company, payment for office services is due at the time services are rendered. We accept cash, check
and credit card payments.
Please be aware that some insurance companies have a limit on their allergy benefit/coverage. Also,
not all services are covered benefits in all contracts. Some insurance companies arbitrarily select certain
services they will not cover. You should verify your benefit/coverage before making an appointment.
We will gladly discuss proposed treatment and answer any questions relating to your insurance. You must
realize, however, that--
1. Our fees are generally considered to fall within the acceptable range by most companies and, therefore, are covered up to the maximum allowances determined by each carrier. This statement does not apply to companies who reimburse on an arbitrary "schedule" of fees, which bears no relationship to the current standard and cost of care in this area.
2. For each month greater than 30 days that your outstanding bill remains unpaid, you will be
assessed a $5.00 finance charge.

3. If your insurance requires a co-pay for specialist as explained in your insurance information your
co-pay will be collected before services are rendered. Starting Jan.1, 2011, there will be a
$10.00 surcharge if the co-pay is not paid at the time of the visit. For each month the bill is
not paid, a surcharge of $5.00 will be added.
4. If your insurance is an HMO, you are responsible to supply this office with the referral and/or authorization forms prior to being examined. Failure to do so may result in denial of coverage,
the fees for which you will be held responsible.
5. You are responsible for informing us of any changes in your insurance plan or policy. Failure to do so may result in denial of coverage, the fees for which you will be held responsible. 6. If you do not have the proper forms described in your insurance handbook, then you MUST reschedule or, if your plan offers "Out of Network" benefits, then you may be seen as an "Out of Network" patient which may result in a somewhat higher cost to you. 7. No show appointments will result in a $225.00 no-show fee for new patients, and a $50.00 no-
show fee for established patients. Patients will not be able to reschedule their appointments
until the no show fee is paid in full. Returned checks will be subject to additional collection fee
of $25.00 or greater.
We will do our best in the filing of insurance claims, however, all charges are ultimately your responsibility. Thank you for your understanding of our Financial Policy, if you have any questions, please do not hesitate to ask. I understand and agree to the Financial Policy of the Allergy Diagnostic and Treatment Center. _________________________________________________ Allergy Diagnostic and Treatment Center • David K. Brown, MD
Christian D. Gonzoph, PA-C • Rebecca A. Rosenberger, PA-C • Kristine M. Cisko, PA-C
33 Overlook Road, Suite # 307, Summit, NJ 07901
Tel . (908) 522-9696/Fax: (908) 522-3070
Acknowledgement of Receipt of Notice of Privacy Practices
I, _______________________________________, have received the Notice of Privacy Practices from the Allergy Diagnostic and Treatment Center, LLC.
X________________________________________________
Date: ________________
Signature of Parent /Legal Guardian/Authorized Person I wish to be contacted in the following manner (check all that apply).
Home: Phone: (_____) _______________
Work: Phone: (_____) _______________
 Leave message with call back number only  Leave message with call back number only Designation of Certain Relatives, Close Friends and Other Caregivers
I agree that the Allergy Diagnostic & Treatment Center may disclose certain of my health information to a family member, close personal friend or other caregiver because such person is involved with my health care or payment relating to such. In that case, the Allergy Diagnostic & Treatment Center will disclose only information that is directly relevant to the person's involvement with my health care or payment relating to such. I designate the following persons listed below as persons involved in my health care or payment relating to such. For the purpose of ADTC making the limited disclosures described above. (I understand that I am not required to list anyone and that I may change this list at any time in writing. Print Name of each designated person below: Staff Only:
In lieu of patient signature, I, ___________________________________, a staff member of the
Allergy Diagnostic and Treatment Center, LLC, state that _______________________________ has
been given our current Notice of Privacy Practices.
Date: ________________
Allergy Diagnostic and Treatment Center • David K. Brown, MD
Christian D. Gonzoph, PA-C • Rebecca A. Rosenberger, PA-C • Kristine M. Cisko, PA-C
33 Overlook Road, Suite # 307, Summit, NJ 07901
Tel . (908) 522-9696/Fax: (908) 522-3070
New Patient Questionnaire
Name:__________________________________________ What is the main reason for your visit? _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Past Medical History: Medical Conditions (please list)
_____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________

Surgeries: (please include the month and year when you had the surgery)
____/______ - _________________________________________________________________ ____/______ - _________________________________________________________________ ____/______ - _________________________________________________________________ ____/______ - _________________________________________________________________

Previous hospitalizations or emergency room visits: Please include the month and year and what
diagnosis was made. (for example: fracture, asthma)
____/______ - _________________________________________________________________ ____/______ - _________________________________________________________________ ____/______ - _________________________________________________________________ ____/______ - _________________________________________________________________ Allergy Diagnostic and Treatment Center • David K. Brown, MD
Christian D. Gonzoph, PA-C • Rebecca A. Rosenberger, PA-C • Kristine M. Cisko, PA-C
33 Overlook Road, Suite # 307, Summit, NJ 07901
Tel . (908) 522-9696/Fax: (908) 522-3070
Medications
Are you on allergy, sinus, asthma, migraine or eczemas medications? Please list name, dosage and how many times daily: ___________________________________________________ ____________ ____________ ___________________________________________________ ____________ ____________ ___________________________________________________ ____________ ____________ What other medications are you taking? This includes over the counter medications. Please list name, dosage and how many times daily: ___________________________________________________ ____________ ____________ ___________________________________________________ ____________ ____________ ___________________________________________________ ____________ ____________ Are you taking any blood thinners such as Coumadin, Plavix, or Aspirin? _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Medication Allergies
Do you have any allergies to medication and if so please list medications and type of reaction you experienced? ___________________________________ _________________________________________ ___________________________________ _________________________________________ ___________________________________ _________________________________________ ___________________________________ _________________________________________ Do you have any sensitivities to medication? (for example upset stomach, fatigue) _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________

Do you smoke? _______ If yes, how many packs a day? _____

Source: http://dkb-allergy.us/word/packet.pdf