we must have these in order to see you...g. do not take antihistamines for____ days prior to appt....

DEAR PATIENT

YOUR APPOINTMENT HAS BEEN SCHEDULED FOR:

DATE:_____________________TIME:_____________________________

WITH: STEVEN ROSENBERG, M.D. FAAAAI

AT THE FOLLOWING OFFICE: ALTAMONTE / WINTER PARK

FOR THE COMFORT OF OUR ASTHMA PATIENTS, PLEASE DO NOT WEAR PERFUMEOR COLOGNE PRODUCTS.YOUR VISIT WILL LAST BETWEEN 2 ½ TO 3 HRS. BRING OR WEAR SHORT SLEEVEDTOP. IN ORDER TO BETTER SERVE YOU, WE ASK THAT YOU PLEASE COMPLETETHE FOLLOWING BEFORE YOUR SCHEDULED APPOINTMENT AND BRINGTHEM WITH YOU. DO NOT MAIL THESE FORMS.

1.) FILL OUT THE INFORMATION AND MEDICAL HISTORY SHEETS COMPLETELY BEFORE YOUR SCHEDULED APPOINTMENT.

2.) ALONG WITH THESE FORMS, PLEASE BRING WITH YOU:

A. YOUR REFERRAL OR AUTHORIZATION NUMBER IF YOU ARE CONTRACTED WITH AN HMO POLICY. (IF APPLICABLE)

B. NAME OF LABORATORY YOUR INSURANCE IS CONTRACTED WITH. (THIS IS VERY IMPORTANT)

C. YOUR INSURANCE CARD(S.) D. ANY RECENT MEDICAL RECORDS FROM A PREVIOUS PHYSICIAN. (INCLUDING CHEST XRAY REPORTS ONLY & CT SCAN REPORTS ONLY PERTINENT TO THIS VISIT.) NO FILMS.

E. A LIST OF YOUR CURRENT MEDICATIONS OR BRING MEDICATIONS WITH YOU.

F. ANY CO-PAYMENT OR CO-INSURANCE PAYMENT THAT MAY APPLY.

G. DO NOT TAKE ANTIHISTAMINES FOR____ DAYS PRIOR TO APPT. DO NOT STOP ANY OTHER MEDICATION.

WE MUST HAVE THESE IN ORDER TO SEE YOU

1890 SR 436, • Ste. 215 • Winter Park • Florida • 32792 • (407)678-4040 • Fax (407) 678-8154685 Palm Springs Dr. • Ste. 1E • Altamonte Springs • Florida • 32701 • (407) 331-6244 • Fax (407) 331-66447232 Sand Lake Rd. • Ste. 100 • Orlando • Florida • 32819 • (407) 370-3705 • Fax (407) 370-9715

WE REQUIRE A 48 HOURNOTICE FOR

CANCELLATIONS IN ORDER

TO AVOID A $50 CANCELLATION

FEE

DR. R PACKET REV. CFS rev. 8/2014

5

ALLERGY, ASTHMA & IMMUNOLOGY ASSOCIATES OF CENTRAL FLORIDA

Home Address:____________________________________

Billing Address: Same as above_____________________

Home Phone:___________________________Cell:____________

Ethnicity:_______________Language preferred:______________

Driver’s Lic. #:____________________Email:_________________

cfs rev. 10/2014

PATIENT INFORMATION

IF PATIENT IS A MINOR PLEASE COMPLETE THIS SECTION

INSURED PARTY and INSURANCE INFORMATION

REFERRAL SOURCE

RELEASE OF INFORMATION and ASSIGNMENT OF BEBFITS

ALLERGY, A STHMA & IMMUNOLOGYA SSOCIATES OF CENTRAL FLORIDA

Central Florida. Allergy, A sthma & Immunology A ssociates of

AAIACF with

Preferred Pharmacy:___________________________________Pharmacy Telephone#:______________________

Allergy, Asthma & Immunology Associates of Central Florida to provide my physician with copies of progressnotes (medical information) concerning my office visit to AAIACF The reason for submission of such informa-tion is to ensure better continuity of patient care.

ALLERGY, A STHMA & IMMUNOLOGY A SSOCIATES OF CENTRAL FLORIDA Steven Rosenberg, M.D., F.A.A.A.A.I.

Page 1

Allergy / Immunology History Form

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Can Food Now Be Eaten?

FAMILY HISTORY

Please not family member with the following disease:M - MotherF - FatherB - BrotherS - SisterC - CousinAsthmaBronchitisEmphysemaHay Fever or Allergic Nose ProblemSinusitisEczema (Atopic dermatitisDrug AllergiesFood AllergiesMigraineTuberculosisRheumatoid ArthritisRheumatic FeverCystic FibrosisFrequent InfectionsDiabetes

A - AuntU - UncleGF - GrandfatherGM - Grandmother

BrotherOr

Sisters

PaternalRelatives

MaternalRelatives

PREVIOUS DISEASE

Measles (Rubeola)German Measles (Rubella)MumpsChicken PoxWhooping CoughScarlet FeverPneumoniaBronchitisAnemiaJaundiceTuberculosisSinus Infections

DiphtheriaTetanusWhooping CoughPolioSmallpoxMeaslesGerman MeaslesMumpsInfluenza

Cfs 12/09/2008

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Date:____________________________________

Last Name First Name Middle Referred By:

Address Phone No.

City State Zip Code

Date of Birth Sex Pediatrician or Family Physician

Father’s Name:________________________________________________Occupation:_____________________________________________

Mother’s Name:________________________________________________Occupation:____________________________________________

DIAGNOSIS HOSPITAL ADMISSIONS (Date & Reason)

1.______________________________________________________

2.______________________________________________________

3.______________________________________________________

4.______________________________________________________

5.______________________________________________________

DRUG REACTION FOOD DISAGREEMENTS Drug Symptom Food Symptom

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Yes No

Yes No

Yes No

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PREVIOUS DISEASE

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ALLERGY AND CLINICAL IMMUNOLOGY PAGE 2

INSTRUCTION: Check (Ö ) Correct Yes or No Boxes

INFANCY HISTORY Yes No

LABORATORY TESTSDate Results

GENERAL Yes No

0 - 5 days6 - 10 days

11 - 20 daysMore than 20 days

FAMILY CONSTELLATION Yes No

Parents: Married Single Divorced WidowedParents Separated

When____________________

Divorced

When____________________

Deceased

Who_____________________ When____________________ Cause____________________

Any Children Deceased

When____________________ Cause____________________Other Children: Number_______

List By

Name Age Sex

NEUROPSYCHOLOGICAL (for children) (please check if application)

TimidQuiet

MaladjustedAggressive

ForwardShy

UnfriendlyExtrovert

DepressedTense

CalmRelaxed

Has FriendsAnxious

DependentIntrovertBustling

HappyIndependent

Well AdjustedComments:

Cfs 12/09/2008

Full Term PregnancyComplicated PregnancyBirth Wt.__________ Lbs.__________ Oz.

Initial Feeding:

Breast

To what age____________________

Formula

Type of formula_________________

To what age____________________

FeedingsTolerated wellMany changesVomitingSpittingDiarrhea

LongerComments:

Other Relatives in Home Who____________________________________

Number of children in Mother’s Family__________________________________

Number of children in Father’s Family__________________________________

Additional Information:_________________________________________

Whole milk started

at __________ months

Colic 0 - 3 months

Sweat TestTB Skin TestOthers

X-Ray

SYSTEMIC REVIEW

Weight LossKeeps up with peersTired all the timeSchool missed last year Missed

School Performance: Explain

Chest


Last Name First Name Middle Date

INSTRUCTION: Check (Ö ) Correct Yes or No Boxes

NERVOUS SYSTEM

NOSEFrequent coldsDischarge: If yes, give color of dischargeBleedsItchStuffiness Constant Seasonal Fall Winter Spring SummerSnifflesSneezingMouth breathingSinusitisSnoring

GASTROINTESTINALNauseaVomitingDiarrheaConstipationGasBelchingAbdominal PainCrampsBlood in stoolsMucous in StoolsFatty or foul smelling stoolsJaundice or HepatitisAppetite: Good Poor

SKINCradle capThrushEczema Cheeks Bend of elbows Behind knees Neck All overHivesPoison IvyInsect bite Reaction Local Generalized

ADDITIONAL INFORMATION

Cfs 12/09/2008

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HeadachesDizziness or LightheadedFaintingConvulsions

Yes No

Yes No

Yes No

Yes No

EYESRednessItchTearingDischargeRubbingPuffiness

EARSPainHearing LossInfectionsMyringotomy ear drums openedTubes inserted

THROATFrequent SoreFrequent ClearingBad BreathVoice changeTonsillectomyAdenoidectomySwollen glandsItchTrouble swallowing

CHESTWheeze Summer Winter Spring FallCough Deep Loose Constant Dry Daytime Nighttime ExertionalShortness of breathPainRattle

Yes No Yes No

Yes No

Yes No

Yes No

GENITOURINARYBedwettingBlood in UrinePainItchingDay wettingInfection: Cystitis or NephritisIs urine stream forceful?

FEMALE HISTORYAge menstual period began:Frequency of periods:Date last normal menstrual period:Bleeding between periods:Duration of periodsExcessive amount of bleeding:

ALLERGY AND CLINICAL IMMUNOLOGY PAGE 5Last Name First Name Middle Date

DIAGNOSTIC SUMMARY (History, Physical Examination, Plan)

Include where and when symptoms started, length and frequency of episodes, known participatingfactors, relationship to fever, seasonal variations, drugs used and their effectiveness.

In patients with eczema and those under one year, include a chronological dietary history.

Cfs 12/09/2008

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INSTRUCTION: Check (Ö ) Correct Yes or No BoxesENVIRONMENTAL SURVEY

LIVING ACCOMMODATIONSPresent address: no. of yearsHouse: no. years oldApartmentIn CityIn CountrySuburbanOn FarmRecent painting or repairsBasement: Dry Damp Musty Smell MildewCarpeting Wool Cotton SyntheticRug pad: Rubber Hair (Ozite)House plants:

BEDROOMNo. of beds in roomSleeps in own roomBed shared with: Other child Parent OtherPillow: Feather (down) Rubber Kapok SyntheticMattress: Cotton Stuffed Foam RubberMattress Encasing: Cotton Chenille OtherBlankets (wool):Comfort (quilt): Cotton DownBedroom rug: Wool Cotton Shag OtherBedroom Rug Underpad: Hair (Ozite) Rubber OtherStuffed ToysDoes child hold or sleepwith anything?If so, what?

Cutting GrassDustingMusty OdorsColdRainExerciseSmokingColdsAnimalsStrong odorsHair SprayPerfume

Cfs 12/09/2008

HEATING SYSTEMEnergy Source: Gas Electric Coal OilType: Radiators Hot Air: Blower Gravity Radiant (baseboard)Electronic Air cleanerHumidifierAir Conditioning: Room Whole house

Yes No Yes No

Yes No

Yes No SMOKINGPatientPacks per dayFatherMotherOthers in contact

Yes No Yes No

PETS Contact In House

Dog CatBirdHorseOther (List)

FAMILY HOBBIES

ARE SYMPTOMS

AGGRAVATED BY:

ADDITIONAL PERTINENT INFORMATION

Yes No

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ALLERGY, ASTHMA & IMMUNOLOGYASSOCIATES OF CENTRAL FLORIDA

( 407)678-4040

Patient Name: DOB:

Date: / /

Brand/Generic Name: Dose Date Date Reactions:Medications Started Stopped

List of Medications

___________________________________

_______________

CFS rev. 7/2014

AAIACF FINANCIAL POLICYWelcome and thank you for choosing Allergy,Asthma & Immunology Associates of Central Florida for your medicalcare! We are committed to providing you with the highest quality care and achieving desired outcomes through a collaborative effort with you, our patient.

It is important that you understand our nancial policy but equally important that you understand the terms of your medical coverage. Although our staff is very knowledgeable about the various insurance plans with which we participate, you are in the best position to understand the detailed terms of your specic plan. Typically, your insurance carrier provides contact information for their Member Services Department on the back of your insurancecard and we encourage you to contact them with specic benet questions or concerns you may have regardingyour coverage.

Our professional fees have been determined through careful consideration of reasonable and customary chargeswithin our geographical area. We are always happy to discuss with you any questions you may have concerning a bill.

INSURANCEPlease remember that your insurance is a contract between you and your insurance carrier. We will, as a courtesy, bill your insurance and help you receive the maximum allowable benet under your policy. We have found that patients who are involved with their claims process are more successful at receiving prompt and accurate payment for services from the insurance carrier. We do expect patients to be interactive and responsible for communicatingwith your insurance carrier on any open claims.

It is your responsibility to provide all necessary insurance eligibility, identication, authorization, referral information and to notify our ofce of any information changes when they occur. Even a pre-authorization of services does not guarantee payment from your insurance carrier. It is the patient’s responsibility to know if our ofce is participatingor non-participating with their insurance plan. Failure to provide all required information may necessitate patientpayment for all charges. When insurance is involved, we are contractually obligated to collect co-payments, co-insurance, and deductibles, as outlined by your insurance carrier.

UNINSURED PATIENTSIf you do not have medical insurance, we will extend cash pay rates to you. These rates are only if payment is made in full at the time of service.

GENERAL

• Please be prepared to pay for the current visit as well as any past due balance on your account at the time of service unless payment arrangements have been made with the billing department prior to your visit.

• If the patient is a minor, the parent(s) or legal guardian(s) are responsible for payment. In cases where a written court document allows payment for medical costs it is the accompanying parents’ responsibility to obtain reimbursement from the other party involved.

• Social Security Numbers are a necessary part of your nancial information with our ofce. This information, as with any of your medical record, is protected with strict condentiality. We are extending a line of credit by ling insurance for your charges and not collecting in full at the time of service, therefore we must have this information. If you do not wish to provide your social security number we will require payment in full at the time of service.

• Balances that remain outstanding more than 60 days after the date of service (or payment by your insurance carrier) will result in a disruption of immunotherapy services and the cancellation of upcoming appointments. The balance may also be considered for referral to an outside collection agency.

.aaacf-fp cfs rev 10/2014 pg 1 of 2

ALLERGY, ASTHMA & IMMUNOLOGY ASSOCIATES OF CENTRAL FLORIDA

• Accounts referred to an outside collection agency or attorney may be subject to a collection fee, which will be added to the original balance.

• Patients with unpaid delinquent accounts or accounts that have been sent to an outside collection agency will be expected to pay their account in full prior to being seen for a non-emergent visit.

• A $35 fee will be assessed for any returned checks, plus any bank fees. We will require all future payments by cash, cashier’s check or debit/credit card.

• A $50 fee will be applied to new patient accounts for no shows and cancellations with less than 24 hour notice.

• A $30 fee will be applied to established patient accounts for no-shows and cancellations with less than 24 hour notice.

• Our ofce is not party to your divorce decree. The nancial responsibility for minors rests with the parent who signs this nancial policy.

IMMUNOTHERAPYA new vial of allergy extract will be routinely ordered once the patient has utilized approximately 2/3 of his/her vial(s). At the time of preparation of the new vial, the patient (or their medical insurance) will be billed for the vial(s). If the patient does not wish, for either themselves or their medical insurance, to be charged for this extract, he/she must notify the ofce staff in writing and in advance of preparation of the extract thathe/she does not wish to receive a new vial. This will result in his/her injection therapy being delayed or discontinued.

FORM COMPLETION AND FEESWe understand that there may be times when you need a form completed by your physician (i.e. medical leave, disability forms) and we are willing to assist you with these requests. These forms require research and time on the part of the staff and physicians. The volume of requests and complexity involved make it difcult to complete them at the time of your visit. We ask that you allow 7-10 business days for completion of these requests. We charge a form completion fee of $8 per page. Payment in full must be made prior to receiving the completed forms.

MEDICAL RECORDSA medical Records Release form must be lled out for the release of any medical records. Records released to the patient for the rst time will be free. Additional copies can be provided for a fee of $1.00 per page for the rst 25 pages and .25 cents for each page thereafter.

aaacf-fp cfs rev 04/7/2014 pg 2 of 2

ALLERGY & ASTHMA ASSOCIATES OF CENTRAL FLORIDA, P.A.

ACKNOWLEDGEMENT OF RECEIPT OF

FINANCIAL POLICY

Effective Date: February 19, 2014

I have received a copy of the AAACF FINANCIAL POLICY (the “Policy”) The Policy describes the financial terms of the Practice to which I must adhere. I understand that I should read it carefully. Patient Name: __________________________ Signature of Patient or Parent (if minor) ______________________________ Date Signed: ________________________ If Parent signed, Print Parent Name: __________________________

ALLERGY, ASTHMA & IMMUNOLOGY ASSOCIATES OF CENTRAL FLORIDA, P.A.

AAICF

ALLERGY, ASTHMA & IMMUNOLOGY ASSOCIATES OF CENTRAL FLORIDA, P.A.

ACKNOWLEDGMENT OF RECEIPT OFNOTICE OF PRIVACY PRACTICE

Effective Date: April 11, 2003

I have received a copy of the Notice of Privacy Practices (the “Notice”). The Notice describes how

my health information may be used or disclosed. I understand that I should read it carefully. In

addition, I am aware that the Notice may be changed at any time. I may obtain a revised copy of the

Notice by requesting one at any of our office locations.

Signature of patient or patient representative:________________________________ Date: ______________

Printed name of patient or patient representative:_________________________________________________

Relationship to patient:_______________________________________________________________________

Cfs 3/24/11 A&AS-HIPPA ACK

we must have these in order to see you...g. do not take antihistamines for____ days prior to appt....

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