For Your Convenience, You Can Download Our Patient Forms Before You Come for Your Initial Visit
To help save you time and unnecessary printing, we have divided up the forms. One section consists of forms you need to bring to the appointment and another section consists of forms you do not need to bring, but should read before the appointment.
Forms You Need to Bring to Your Initial Visit
Please make sure to print all of the forms (10 pages total), fill them out, sign and date where appropriate, and bring them to your appointment. Please also remember to bring your insurance card, driver's license, and referral (if required by your insurance company).
Forms You Do NOT Need to Bring to Your Appointment
These forms contain our general insurance and HIPAA policies. We recommend that you read these before your appointment.
Review Insurance & HIPAA Policies
Thank you again for selecting our office for your treatment. We look forward to meeting you soon. Please don't hesitate to contact us if you have any questions or concerns.
Read about our "Red Flag" policy and how it relates to you as a patient.
Effective date: August 1, 2009
Allergy and Asthma Center of Rochester, Michigan
Identity Theft Prevention Program -- Red Flag Rules
Effective August 1, 2009, the Allergy and Asthma Center of Rochester must comply with the Fair and Accurate Credit Transactions Act of 2003 (FACTA) as amended in October of 2007 to include Red Flag and Address Discrepancy Requirements (Red Flag).
Frequently Asked Questions
Why was FACTA amended to include Red Flag Rules?
The Red Flag rules are designed to protect consumers from identity theft by requiring businesses like the Allergy and Asthma Center of Rochester to recognize activities that indicate the possible existence of identity theft.
What kind of activities will Allergy and Asthma Center of Rochester watch for that may indicate identity theft?
Some things that may indicate identity theft, or "Red Flag" activities that the Allergy and Asthma Center of Rochester will watch for are:
- Documents provided for identification appear to have been altered or forged.
- The photo ID provided by the patient is not consistent with the appearance of the patient requesting treatment.
- The SSN, birth date or other personal information provided is the same as that submitted by another patient.
- The patient requesting treatment is not able to produce personal identifying information, such as driver’s license or insurance card.
- Notice from patients that they have received an Explanation of Benefits from their insurance company for services they never received.
- Medical records report, medical treatment or conditions that are inconsistent with a physical exam or medical history as reported by the patient.
What will the Allergy and Asthma Center of Rochester do if it finds 'Red Flag' activities on my account?
The Allergy and Asthma Center of Rochester has created policies and procedures to reduce the opportunity for identity theft, recognize signs of identity theft (Red Flags), and respond to 'Red Flags' when identified. The Allergy and Asthma Center of Rochester staff has been trained on these policies and procedures and will monitor and update these policies for their effectiveness. Depending on the type of 'Red Flag' identified, the Allergy and Asthma Center of Rochester staff may do one or more of the following:
- Flag an account for suspected identity issues so that the Allergy and Asthma Center of Rochester staff will be alerted to watch for suspicious activity.
- Verify information provided by the patient by researching public information like the Social Security Administration’s Death Master File.
- Contact a patient to discuss a concern about a possible identity theft.
What will the Allergy and Asthma Center of Rochester do to reduce the risk of identity theft?
The Allergy and Asthma Center of Rochester requires a copy of a picture ID for each patient; this is used to confirm the patient’s identity and is kept in a secure protected environment for the Allergy and Asthma Center of Rochester’s use only. The Allergy and Asthma Center of Rochester has security policies in place to ensure that your data is safe from exposure or release to other parties. Our staff is trained in patient privacy, committed to protecting your information and on the alert for suspicious activity.
What can I do to protect my identity?
As a consumer of medical services, there are several things you can do to help safeguard your identity, here are some suggestions:
- Safeguard your medical information; keep your medical insurance ID card and other information in a secure place like you would a credit card.
- Request an annual listing of all benefits paid by your insurer and review to be sure only services you or your dependents received are listed.
- If fraudulent activity is suspected, be proactive in contacting the provider of service and investigating the situation.
- Check your credit report. Starting in December 2004 you can get a free copy of your report from the three national consumer reporting agencies, depending on where you live. For more on free credit reports and how you can get yours, see PRC Fact Sheet 1, Privacy Survival Guide, www.privacyrights.org/fs/fs1-surv.html