1620 South Queen Street, York, PA t: f: West Elm Avenue, Hanover, PA t: f:

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1 Specializing in Allergy & Asthma Care for Over 30 Years Gregory B. Lanpher, M.D. Founder South Queen Street, York, PA t: f: West Elm Avenue, Hanover, PA t: f: Welcome to our practice! Please plan to arrive minutes before your appointment to process paperwork. Thank you for choosing Allergy and Asthma Consultants Inc. We are committed to providing you with the highest quality allergy and asthma care to improve your health and well-being. Enclosed you will find an information packet. It is important that you fill out the paperwork prior to your appointment so that our providers get the best information possible, and you get the maximum benefit from your office visit. Appointment Information: : Time: Provider At the following office: o York Office 1620 South Queen Street, York PA Main Entrance and Parking Lot is at the rear of the building o Hanover Office 420 West Elm Avenue, Hanover PA Please allow 2-3 hours for your initial evaluation and testing. Minors under the age of 18 must be accompanied by a parent or legal guardian with appropriate documentation. Plan to wear a short sleeved or sleeveless top that allows access to your upper arms where the skin tests will be applied. Certain medications interfere with skin testing. Please review the enclosed Restricted Medications for Testing instructions, and call us if you have any questions regarding your medications. The charges for your initial visit could range from $200-$1000, depending on testing services provided. We encourage you to verify your insurance coverage for your co-pay, deductible and co-insurance responsibility. Please bring the following items with you to your appointment: All enclosed forms, fully completed. Current insurance card(s). If you do not have insurance, you will be required to pay for your visit at the time of service with either a Credit Card or Cash. Referral, if required by your insurance plan. Patients without referrals are responsible for payment in full. Co-Pay, if required by your insurance plan, must be paid at time of service. Pertinent medical records that would be helpful for your evaluation. We require at least a 48 hour notice for cancelling or rescheduling this appointment. If two (2) missed or cancelled appointments occur without adequate notice, our office reserves the right to not schedule any more appointments, and to charge you a fee. Our office is Fragrance-Free. Perfumes, colognes and lotions can cause severe, life-threatening asthma attacks. We ask you and accompanying family members or friends to refrain from applying fragrances whenever you come to our building. Persons wearing detectible fragrances will be asked to leave the building. We look forward to seeing you soon!

2 Restricted Medications for Testing Certain medications, particularly antihistamines, can interfere with allergy testing. For this reason, any medication(s) containing antihistamines must be stopped five (5) days prior to your appointment, to enable testing if recommended by the provider. This includes all prescription and over-thecounter allergy, cough and cold medications. Some examples of medications containing antihistamines: Allegra, Astepro, Claritin, Benadryl, etc. Over-the-counter sleep aids, such as Tylenol PM, Sominex, etc. Some stomach medications, such as Zantac, Pepcid, Tagamet, etc. If you are on an antidepressant which acts like an antihistamine (Elavil, tricyclics), please contact your prescribing doctor to see if you can safely go off it for five (5) days. CONTINUE TAKING ALL OTHER MEDICATIONS as prescribed, including asthma medications. Please call us if you have any questions regarding the discontinuation of any medications.

3 Please Print Clearly ALLERGY AND ASTHMA CONSULTANTS INC. PATIENT DEMOGRAPHIC INFORMATION PATIENT First Name Middle Initial Last Name Today s Social Security # Gender of birth Age Marital Status Race: Ethnicity: Preferred Pharmacy Address Home address City State Zip address Home ph # Cell ph # Preferred Phone (Circle): Home/Work/Cell Preferred Method of Communication (Circle): Phone/Mail/Fax Employment status (Circle): Employed full-time Employed part-time Self-employed Unemployed Retired Full-time student Part-time student Employer Occupation Work ph # Primary Care Physician Physician ph # Emergency Contact Relationship Phone # Family Members who are patients Please complete if patient is married SPOUSE INFORMATION Spouse First Name Middle Initial Last Name SS# of birth Home ph # Cell ph # Home address City State Zip Employer Occupation Work ph # Please complete if patient is a minor/student MOTHER (or GUARDIAN) INFORMATION If Legal Guardian, relationship to patient First Name Middle Initial Last Name SS# of birth Home ph # Cell ph # Home address City State Zip Employer Occupation Work ph # FATHER (or GUARDIAN) INFORMATION If Legal Guardian, relationship to patient First Name Middle Initial Last Name SS# of birth Home ph # Cell ph # Home address City State Zip Employer Occupation Work ph # HIPAA Contacts: Authorization to Release Protected Health Information to the following individuals. Name: Phone # Relationship Name: Phone # Relationship Name: Phone # Relationship Signature of Patient or Parent/Guardian/Responsible Party

4 ALLERGY AND ASTHMA CONSULTANTS INC. PATIENT INSURANCE INFORMATION PRIMARY INSURANCE Effective ID # Group # Policy Holders Name SS# of Birth Address City State Zip Home Phone # Cell ph # Relationship patient Employer SECONDARY INSURANCE Effective ID # Group # Policy Holders Name SS# of Birth Address City State Zip Home Phone # Cell ph # Relationship to patient Employer PATIENT ACKNOWLEDGEMENT AND AUTHORIZATION - ALL INSURANCES 1. Consent for Medical Care and Treatment I hereby authorize Allergy and Asthma Consultants Inc. to furnish medical care and treatment as considered necessary and proper in diagnosing or treating my/his/her medical condition. 2. Authorization To Release Medical Information I hereby authorize Allergy and Asthma Consultants Inc. to release any and all medical records in its possession without further authorization, (I) to any other physician or other healthcare provider in order to render patient care, and (II) to my insurance carrier(s) in order to obtain payment of financial obligations to Allergy and Asthma Consultants Inc. 3. MEDICARE or MEDICARE ADAVANTAGE SIGNATURE ON FILE I request that payment of authorized Medicare benefits be made on my behalf to Allergy and Asthma Consultants Inc. for any services furnished to me by them. I authorize Allergy and Asthma Consultants Inc. to release to Medicare and its agents any medical or other information necessary to determine these benefits or the benefits payable for related services. I request that payment of Secondary benefits be made on my behalf to Allergy and Asthma Consultants Inc. for any services furnished to me by them and also authorizes AAC to release to the Secondary insurer any information necessary to determine benefits payable for related services. 3. Authorization for Payment of Insurance Benefits I hereby authorize payment of insurance benefits directly to Allergy and Asthma Consultants Inc. I understand that I am financially responsible for the payment of charges not covered by this assignment. 4. Acceptance of Financial Responsibility I accept full financial responsibility for the payment of medical care and treatment according to Allergy and Asthma Consultants Inc. Financial Policy. My signature below also acknowledges receiving a copy of this document. This authorization shall remain in effect until rescinded by patient or authorized individual. Patient Name (Please Print) of Birth Parent/Guardian/Responsible Party (Please Print) Relationship to Patient Signature of Patient or Parent/Guardian/Responsible Party Revised 2016

5 Specializing in Allergy & Asthma Care for Over 30 Years Gregory B. Lanpher, M.D. Founder South Queen Street, York, PA t: f: West Elm Avenue, Hanover, PA t: f: Patient Information Patient Name: of Birth: Today s : Family Physician: Referred by: Reason for Consult/Your symptoms: What are your symptoms worsened by? Cats Dogs Dust Trees Grass Perfume Tobacco Smoke Past Allergy History Previous allergy testing Previous allergy injections Currently receiving allergy injections Minor or Major reactions to allergy injections Food Stress Colds Exercise yes/no yes/no yes/no yes/no Wind Damp, musty areas Air conditioning When do your symptoms occur? Spring Fall Summer Winter Weather or temperature changes Medication/Drug: Anesthesia/Immunization: Stinging Insects: Food Allergy/Intolerance: Latex Allergy/Other allergy: Please list any past allergic reactions Please list all current medications Medication Name Dose Times per day Medication Name Dose Times per day 1 Please use additional space provided at the end of this document if needed

6 Please check any symptoms that you have recently had, or are currently experiencing General: Head: Ears: Eyes: Nose: Throat: Cardiovascular: Respiratory: Gastrointestinal: Genitourinary: Endocrine: Musculoskeletal: Skin: Allergy/ Immunology: Neurologic: Heme/Lymph: chills, fatigue, fever, night sweats, weight gain, weight loss, other dizziness, headache, recurrent sinus infection, sinus pain, sinus problems, other earaches, clogged ears/blocked ears, hearing problems, recurrent infections, ringing or popping, ear drainage, other drainage, dry eyes, itchy eyes, red eyes, vision problems, watery, blurred vision, darkness under eyes, double vision, other itchy nose, nasal congestion, nose bleeding, postnasal drip, runny nose, sneezing, nasal discharge, other hoarseness/laryngitis, itching, sore throat, difficulty swallowing, excessive snoring, recurrent infections, other chest pain, high blood pressure, increased heart rate, palpitations, other chest pain, chest tightness, cough, short of breath on exercise, shortness of breath at rest, wheezing, recurrent pneumonia, other abdominal pain, bloating excessive gas, diarrhea, food intolerance, heartburn/indigestion, nausea/vomiting, reflux, other increased urinary frequency, painful urination, urine retention, other excessive thirst, tired or sluggish, too hot/cold, other back pain, joint pain, joint redness, joint swelling, neck pain, other hives, persistent itch, skin rash, dry swelling, eczema, boils, easy bruisability, recurrent infections, other drug allergy, food allergy, hay fever, insect allergy, recurrent infections, other dizzy spells, numbness, tingling, tremors, other bleeding disorders, blood clotting problem, swollen glands, other Please list any allergy/asthma medications that you have tried in the past Medication Name Was it helpful? Medication Name Was it helpful? 2 Please use additional space provided at the end of this document if needed

7 Family History Father Yes/No Yes/No Mother Yes/No Yes/No Brother Yes/No Yes/No Sister Yes/No Yes/No Daughter Yes/No Yes/No Son Yes/No Yes/No Maternal Side Yes/No Yes/No Paternal Side Yes/No Yes/No Family (General) Yes/No Yes/No Asthma Allergies Other significant Conditions Family History is Unknown Social Profile Marital Status Occupation Children Hobbies Exercise Level Alcohol use Other household members Single / Married / Divorced / Separated / Widowed Yes / No Rare / Intermittent / Regular Full time / part time / unemployed Tobacco Exposure: Please indicate your tobacco status by checking the following: No Tobacco Exposure Current smoker Exposed to second-hand smoke: (circle any that apply) home/work/socially Past smoker Environmental Profile Please circle Type of Cooling: central air conditioning / window unit(s) Type of Heat: electric / forced air / gas / baseboard / propane / oil / wood stove / fireplace / radiator / kerosene / heat pump / geothermal system / other Type of Flooring: Bedding: Animal Exposure: Mold/Mildew: hardwood flooring / tile flooring / laminate / vinyl/linoleum / stone other How old is your mattress? Is there a protective dust mite cover? yes/no How old is your pillow? Is there a protective dust mite cover? yes/no Are you exposed to animals? yes/no What type of animals? cat(s) / dog(s) / other Do the pets have access to the bedroom? yes/no Is there evidence of mold/mildew in the home/workplace? yes/no Are there houseplants in the home? yes/no If yes, how many? 3 Please use additional space provided at the end of this document if needed

8 Past Medical History In the Past, have you ever had symptoms of, or been treated for, any of the following diagnoses: Allergies Migraine Headaches Asthma Skin Allergy Heart Disease Bronchitis Anxiety Hyperlipidemia COPD Arthritis Hypertension Drug Allergy Cancer Irritable Bowel Recurring Ear Infections Depression Kidney Disease Eczema Diabetes Thyroid Problems Food allergy/intolerance GERD/Reflux Past Surgical History Past Hospitalization Type of surgery Reason for hospitalization Past ER Visits Last X-ray/CT Scan Reason for ER visit Type of X-Ray/CT Scan Additional information: GlobalShare\Front Desk\Forms\New Patient Questions Please use additional space provided at the end of this document if needed

9 FINANCIAL POLICY Thank you for choosing Allergy and Asthma Consultants Inc. We are committed to building a successful physician-patient relationship with you and your family. If you have any questions regarding our financial policy, please contact us at No Insurance Coverage Payment in full is required at time of service. We accept cash or credit cards; Visa, Discover, MasterCard or American Express. Insurance Coverage It is the patient s responsibility to fully understand your insurance coverage and benefits prior to your office visit. Upon registration at each visit, please present your current insurance card(s), co-pay, referrals and/or authorizations required by your plan. It is the policy of this office that all patients or their guarantors are financially responsible for the services provided, regardless of the nature or extent of any insurance coverage. Any questions regarding payment of claims should be directed to your insurance company. Patient Statements Payment in full must be made by the Due printed on the Patient Statement. Cash, checks, money orders, MasterCard, Visa, Discover and American Express are accepted forms of payment. If you are unable to remit in full, please contact our billing department at to assist in setting up a payment plan. Immunotherapy Balances (Applies to patients receiving allergy injections) Any unpaid balance must be paid in full prior to the renewal of your next 6 month supply of Extract. Delinquent Balances Balances that remain unpaid after 90 days are considered delinquent and subject to debt collection. If you are unable to remit the entire balance due within this 90 day period, please call our billing department to arrange a payment plan. Failure to contact us and setting up a payment plan may result in your account being turned over to an outside collections agency. At that time a fee equal to 30% of the delinquent amount will be assessed to your balance. Delinquent balances must be paid prior to new services being rendered. Future services must be paid in full at the time of service for any account turned over to an outside collection agency. Bankruptcy If an account is uncollectable due to bankruptcy, future services must be paid in full at the time of service. Financial Responsibility for Minor Children of Separated or Divorced Parents Allergy and Asthma Consultants Inc. will not be a party to separation/divorce billing disputes. The parent or legal guardian, who requests and consents to the treatment of a child, will be responsible for the payment of services rendered. Administrative Fees Checks Returned by the bank are assessed a $35 returned check fee. Credit Account Balances of less than $5.00 will not be refunded unless requested by patient. Letters and Forms requiring medical review and physician signature, including FMLA, Disability or other documents, are subject to administrative fees. Administrative fees may be waived if the patient has a scheduled appointment in conjunction with form completion. Please allow 7-10 days for form completion. Medical Record copying fees are charged in accordance with the Pennsylvania Judicial Code and federal law. Overnight Delivery of allergen extracts or documents is charged according to Federal Express standard rates. AAC Financial Policy - Revised March 2016