• Asthma & Allergy Associates, Sterling/Troy, P.C.
    Brandon D. Ross, M.D.
    Dr. Anne Erben, M.D.
    2950 East Wattles Road, Suite 300
    Troy, Michigan 48085
    Tel: (248) 524-2121
    Fax: (248) 524-2035
  • Registration Form

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  • THERE WILL BE A $25.00 CHARGE FOR CANCELING AN APPOINTMENT WITHOUT A 24 HOUR NOTICE.ALL CO-PAYS, CO-INSURANCE, DEDUCTIBLE AND UNCOVERED SERVICES WILL BE THE RESPONSIBILITY OF THE PATIENT OR THE PARENT OR GUARDIAN WHO BRINGS THE PATIENT IN AT THE TIME OF SERVICE. WE CAN GIVE YOU AN ITEMIZED RECEIPT IF YOU REQUIRE ONE.

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  • Assignment and Release

    I, the undersigned, have insurance coverage with 

  • and assign directly to Dr. Brandon Ross 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.

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  • Medicare Authorization
    I request that payment of authorized Medicare benefits be made either to me or on my behalf to Dr. Brandon Ross for any services furnished me by that physician. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable for related services. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If “other health insurance” is indicated in the item 98 of the HCFA-1500 form, or elsewhere on other approved claim forms or electronically submitted claims, my signature authorizes releasing of the information to the insurer or agency shown. In Medicare assigned cases, the physician or supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, coinsurance, and non-covered services. Coinsurance and the deductible are based upon the charge determination of the Medicare carrier.

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  • ALLERGY / ASTHMA QUESTIONNAIRE

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  • Medication Sheet

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  • Symptoms you are currently having

  • Allergy History

  • Social History:

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  • Family Medical History:

  • Environmental:

  • Dwelling

  • Primary Residence

  • HIPPA

  • NOTICE AND ACKNOWLEDGEMENT

    I acknowledge that I have received or have been offered a copy of the Notice of Privacy Practices.
    (Found on website or receptionist can provide a copy if you would like one)

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  • PERSONAL REPRESENTATIVE

    Please list the names of any person that we may share your personal health information with. By listing the following persons, you are informing us of your wish to designate them as your personal representatives, which is your right as per HIPAA. You may revoke authorization at any time.

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  • WAIVER FOR UNDER THE AGE OF 18 TO BE SEEN WITHOUT PARENT OR GUARDIAN

     

  • I Parent/ Personal Rep give my permission for Patient to receive treatment without my attendance.

  • COMMUNICATION RESTRICTIONS

     

  • PHARMACY INFORMATION

    Please list below the name, city, and phone number or crossroads of the pharmacy where you would like your prescriptions sent. If you utilize a mail order pharmacy please circle the name at the bottom. 

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