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Asthma & Allergy Medical Care

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Patient's or Authorized Person's Signature
I the undersigned give my authorization to treat and assign directly to Asthma & Allergy Medical Care , all medical benefits, if any, otherwise payable to me for services rendered. I understand that I am ultimately financially responsible for all approved and covered 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. I understand that payment is expected at the time of service.

I acknowledge receipt of the Practice's Notice of Privacy Practices. I authorize the Practice to use and disclose my health information for purposes of treating me, obtaining payment for services rendered to me, and conducting healthcare operations.
Asthma & Allergy Medical Care
08 Nassau Road " Huntington, NY 11743
Please attach all pertinent insurance ID cards for photocopying.
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Phone:631-423-5590 Email: