INSURANCE INFORMATION Policy/Subscriber: PARENT/LEGAL GUARDIAN AND EMERGENCY CONTACT INFORMATION Parent/Legal Guardian Name:

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1 PATIENT INFORMATION Patient #: Gender: Date f Birth: Last Name: Age: First Name: Initial: Scial Security #: Address: City, State, Zip: Hme Phne: Wrk Phne: RESPONSIBLE PARTY Accunt # Patient Relatinship t Guarantr: Last Name: Gender: Marital Status: First Name: Date f Birth: Address: Scial Security #: City, State, Zip: Hme Phne: Emplyer: Emplyer Address: Wrk Phne: City, State Zip: Primary Care Physician: Telephne #: Primary Insurance: Address: City, State, Zip: Plan Phne: Effective Dates: Secndary Insurance: Address: City, State, Zip: Plan Phne: Effective Dates: INSURANCE INFORMATION Plicy/Subscriber: Insured Plicy ID: Grup Number: Date f Birth: Patient Relatinship t Subscriber: Plicy Subscriber: Insured Plicy ID: Grup Number: Date f Birth: Patient Relatinship t Subscriber: PARENT/LEGAL GUARDIAN AND EMERGENCY CONTACT INFORMATION Parent/Legal Guardian Name: Emergency Cntact: Address(if different than patient): Parent Hme Phne: Address(if different than patient): Patient relatinship t Cntact: Cntact Hme Phne: Parent Wrk Phne: Cntact Wrk Phne: MEDICAL AUTHORIZATIONS AND RELEASE OF INFORMATION I hereby authrize Arizna Asthma and Allergy Institute t furnish the insured s insurance cmpany all infrmatin which said insurance cmpany may request cncerning my present illness r injury. I hereby assign t the dctrs all mney t which I am entitled fr medical and/r surgical expenses relative t the services perfrmed. It is understd that any mney received frm the abve named insurance cmpany ver and abve my indebtedness will be refunded t me when my bill is paid in full. I understand that I am financially respnsible t said d fr all charges, I hereby authrize Arizna Asthma and Allergy Institute t prvide such medical services including surgery, if necessary, either regular r emergency, as may be determined t be in the best interest f the patient listed abve. This authrizatin shall cntinue and be in fu and effect until revked in writing by me. X Signature Date:

2 Arizna Asthma & Allergy Institute New Patient Histry Frm 5605 W. Eugie, Suite E. Muntain View, Suite E. Baseline Rd Suite W. Ranch Sante Fe Blvd. Suite A-100 Glendale, Arizna Scttsdale, Arizna Gilbert, AZ Avndale, AZ NAME AGE DATE DATE OF BIRTH SEX PATIENT'S REGULAR DOCTOR Referred by WHAT PROBLEMS DO YOU WANT EVALUATED (Circle) 1. Hay fever r nasal prblems 2. Eye symptms 3. Sinus and/r Ear prblems 4. Breathing difficulties- Asthma, brnchitis, cugh, etc. 5. Skin prblems- Hives r swelling, eczema, r ther rash 6. Insect reactin (lcal swelling) 7. Drug reactin 8. Fd reactin 9. Headaches 10. Other WHAT ARE YOUR SYMPTOMS (Circle apprpriate symptms) Nasal Symptms hw many years? nasal discharge- clear, yellw, green pst nasal drip sneezing nasal itchiness nasal cngestin frequent nse blwing lss f smell/taste thrat itchiness daily, weekly, seasnal? Chest Symptms cugh, wheeze, shrtness f breath hw lng? daily, weekly, r mnthly? chest tightness waking up at night hw many nights per week? d yu cugh up anything? What clr? have yu tried any inhalers r albuterl? d yu have a nebulizer r breathing machine? d yu have a peak flw meter? hw many severe episdes in the last year? have yu used prednisne r ral sterids? have yu been t the emergency rm? have been hspitalized fr the chest symptms? When? d yu have stmach reflux? d yu have prblems with exercise? Sinus Symptms frequent sinus infectins facial pain and tenderness tth pain pressure and cngestin clred nasal discharge headaches Eye Symptms itchiness, redness, puffiness watery discharge eyelid irritatin dark circles under eyes d yu use eye drps? Skin symptms hives, welts, red patches, itchiness eczema areas f swelling hw lng? family histry f swelling r eczema? recent infectin? recent antibitic use? WHAT TRIGGERS YOUR SYMPTOMS? (Circle) (Beside each circled item, N=nasal, C=chest) ALLERGIES INFECTION OTHER pllens (grass, weeds, trees) N C viral clds N C antibitics N C animals (cat, dg, hrse) N C sinus infectin N C aspirin N C mld/mildew N C chemicals N C dust N C insects N C fds N C ther IRRITANTS IRRITANTS UNKNOWN weather changes N C wdstve/fireplace N C emtins N C wind N C strng drs N C stress N C cld air/humidity N C perfumes/chemicals N C laughter N C exercise N C tbacc smke N C crying N C (1)

3 CIRCLE WHICH MONTHS YOU HAVE SYMPTOMS Nse/Ears JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC Sinus JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC Breathing JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC Skin JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC Patient Name ENVIRONMENTAL HISTORY (Circle) Current residence: city Length at this lcatin Previus lcatins: Resident type: Huse Cnd Apt Mbile hme Landscaping: Desert Grass Trees Decrative gravel / rck Neighbrhd: Residential Rural Agricultural Industrial Business Heating: Gas Electric Wd stve Other Cling: Air cnditining Swamp cler Central Rm nly Nne Other Allergen air filtratin: Nne Small bedside Electrnic HEPA Smkers at hme? N Y If yes, wh: Flring: Carpet Tile Wd Linleum Area rugs Cncrete Bedrm: Bx spring mattress Waterbed Bunk bed Futn Mattress cvered in plastic Pillws: Plyester Fam Feather Nne Animal Expsure: Nne Cat Dg Hrse Rabbit Hamster Gerbil Bird In bedrm In Huse Outside nly Parents/Baby sitters Wrk: Type f wrk Number f wrk days missed ver the past 12 mnths Are yur symptms wrse at wrk? N Y Describe Schl: Daycare Elementary Junir High High Schl Cllege Number f schl days missed ver the past 12 mnths Are yur symptms wrse at schl? N Y Describe If daycare- is there expsure t: animals wd stves tbacc smke CURRENT MEDICATIONS (List medicines taken fr any reasn including aspirin, bld pressure, thyrid, nse sprays, etc.) Name f medicatin Dse Hw ften taken Additinal medicatins PRIOR ALLERGIC REACTIONS Drug Reactin: Medicatin Reactin Medicatin Reactin Medicatin Reactin Insect Reactin: Insect type Reactin When did this ccur? Symptms: tngue r thrat swelling hives shrtness f breath wheeze lcal swelling Fd Reactin: What were yu eating? Time frm eating t nset f reactin? Symptms: tngue r thrat swelling hives nausea vmiting diarrhea shrtness f breath wheeze PREVIOUS ALLERGY CARE (Circle thse that apply) 1) Never tested befre 2) Tested befre: skin tests bld tests Negative Psitive Grass Weeds Trees Dust Animals Mlds Fds 3) Allergy shts? N Y If yes, name f dctr and lcatins Dates t Degree f help: Nne Slight Mderate Great 4) Previus sinus x-ray r CT scan? 5) Previus ENT r Pulmnary evaluatin? 6) Previus CXR? (2)

4 Patient Name Patient Past Medical, Family, and Scial Histry Frm 200 Have yu had any f the fllwing Yes N Describe the prblem when apprpriate 1. Abnrmal chest x-ray 2. Anesthesia cmplicatins 3. Anxiety, depressin r mental illness 4. Bld prblems (abnrmal bleeding r anemia) 5. Diabetes 6. Grwth remved frm the cln r rectum 7. Hepatitis 8. High bld pressure 9. High chlesterl r triglycerides 10. Sexually transmitted disease 11. Strke r TIA 12. Treatment fr alchl and/r drug abuse 13. Tuberculsis r psitive tuberculin skin test 14. Csmetic r plastic surgery Indicate whether yu have ever had a medical prblem and/r surgery related t each f the fllwing by placing a check( ) in the fllwing apprpriate bx(es). If yu have had surgery, indicate the apprximate year(s) f surgery. Describe the prblem and type f surgery. (Circle) the apprpriate chice when multiple chices are listed in a questin: Medical Year(s) f Prblem Surgery Surgery Describe 1. Eyes (cataracts, glaucma) 2. Ears, nse, sinuses, r tnsils 3. Thyrid r parathyrid glands 4. Heart valves r abnrmal heart rhythm 5. Crnary (heart) arteries (angina) 6. Arteries (arta, arms, legs) 7. Veins r bld clts in the veins 8. Lungs (pneumnia, valley fever) 9. Esphagus r stmach (ulcer, reflux) 10. Bwel r appendix 11. Liver r gallbladder 12. Pancreas 13. Hernia 14. Lymph ndes r spleen 15. Kidneys r bladder 16. Bnes, jints r muscles 17. Back, neck r spine 18. Brain (headaches, seizures, depressin) 19. Skin 20. Females: breasts, uterus, tubes, varies 21. Males: prstate, testes, vasectmy Pediatric Histry (Please fill ut this sectin if patient is <12 years ld) Pregnancy: Full term Preterm Describe Cmplicatins during pregnancy Labr and delivery: Nrmal Cmplicatins Describe Newbrn nursery curse: Nrmal Cmplicatins Describe Grwth and develpment: Nrmal Cmplicatins Describe Immunizatins up t date: Yes N Histry f RSV infectin? (3)

5 FAMILY MEDICAL HISTORY (Indicate any medical, allergic, r respiratry disrders) Mther Father Brther/Sister Grandparents Other Patient Name SOCIAL HISTORY Educatin: Hw many years f schl have yu cmpleted? Occupatins: Yur current emplyment status: Emplyed Retired Hmemaker Student Unemplyed Emplyed-current ccupatin(s): Previus Occupatins/Jbs: Spuses Emplyment Parent s Emplyment Disability: Are yu disabled: N Yes Abuse: Have yu ever been physically, sexually, r emtinally abused? N Yes Have yu used any f the fllwing substances? Substance Currently Previusly Type/Amunt/Frequency Hw Lng? If stpped, Use? Used (Years) when?(years) Tbacc Yes N Yes N Alchl-beer wine, liqur Yes N Yes N Caffeine-cffee, tea, sda Yes N Yes N Recreatinal/Street drugs Yes N Yes N Marital Status: Are yu currently married? N Yes In what year did this marriage ccur? List any previus marriages (year married and duratin): Current Spuse: Nt applicable Alive (Name ) Deceased Health prblems r cause f death: Reviewed and anntated by: (Physician nly) Signature Date Signature Date (4)

6 REVIEW OF SYSTEMS Frm 201 Patient Name Indicate whether yu have experienced the fllwing symptms during recent mnths, unless therwise specified, by checking Yes r N fr each questin. Circle the symptm(s) yu have experienced when multiple symptms are listed in a questin. If yes, please explain. YES NO Ntatin 1. Skin rash, hives, itchiness, dry skin? 2. Unhealing sres, excessive bruising r change f a mle 3. Excessive thirst r urinatin? 4. Weight gain r lss, cld intlerance, r tremr? 5. Change in sexual drive r perfrmance? 6. Significant headaches, seizures, blurred speech r difficulty mving an arm r leg? 7. Numbness r tingling f hands r feet? 8. Eye prblems such as duble visin, cataracts r glaucma? 9. Diminished hearing, dizziness, harseness, sinus prblems r nasal plyps? 10. D yu wear dentures? (If yes: Full Upper Lwer Partial) 11. Bthered with cugh, shrtness r breath, wheezing r asthma? 12. Cughing up sputum r bld? 13. Expsed t anyne with tuberculsis 14. Blacked ut r lst cnsciusness? 15. Chest pain r pressure, rapid r irregular heart beats 16. Awakening at night with shrtness r breath? 17. Abnrmal swelling in the legs r ft? 18. Pain in the calves f yur legs when yu walk? 19. Difficulty with swallwing, heartburn, nausea, vmiting r stmach truble? 20. Prblems with cnstipatin, diarrhea, bld/changes in bwel mvement? 21. Have yu had a cln r rectum x-ray? 22. Have yu undergne prtscpy, sigmidscpy, r clnscpy? 23. Difficulty starting yur urinary stream r cmpletely emptying yur bladder? 24. Leaking urine r bld in the urine? 25. Burning sensatin r pain with urinating 26. Pain, stiffness r swelling in yur back, jints r muscles? 27. Fever within the last mnth? 28. Enlarged glands (lymph ndes)? 29. Experiencing an unusually stressful situatin? 30. Weight gain r lss f mre than 10 punds during the last 6 mnths? 31. Prblems falling asleep, staying asleep, sleep apnea r disruptive snring? 32. Abnrmal nipple discharge r a breast lump? 33. Have yu every felt a need t cut dwn n yur alchl cnsumptin? 34. D relatives/friends wrry r cmplain abut yur alchl cnsumptin? 35. Have yu been physically, sexually, r emtinally abused? QUESTIONS TO BE ANSWERED BY FEMALE PATIENTS ONLY: 36. Have yu ever had an abnrmal Pap smear? Unknwn 37. Have yu experienced menpause r had a hysterectmy? 38. If n: Are yu cncerned abut yur menstrual perids? 39. Might yu be pregnant at this time? 40. Date r nset f yur last menstrual perid: m:: day: yr: 41. Apprximate date f yur last Pap smear r pelvic exam: m: day: yr: 42. Apprximate date f yur last mammgram: m: day: yr: 43. Number f:: Pregnancies Live Births Miscarriages/abrtins Reviewed and anntated by: (Physician nly) Signature Date Signature Date (5)

7 Acknwledgement f Receipt f Privacy Ntice Original t be maintained in Patient s permanent medical recrd. I acknwledge that I have received a cpy f the ffice s Ntice f Privacy Practices. Printed Patient Name Acct# Patient r legally authrized individual signature Date Relatinship (parent, legal guardian, persnal representative, etc.) 4001 E. Baseline Rd, Suite 201 Gilbert, AZ Fax# W. Ranch Sante Fe Blvd,.Suite A-100 Avndale, AZ Fax# W. Eugie Avenue, Suite 200 Glendale, Arizna Fax East Muntain View, Suite 200 Scttsdale, Arizna FAX

8 Welcme T Our Practice! Thank yu fr chsing AAAI t partner in yur healthcare needs. We are cmmitted t prviding yu with quality and affrdable health care. Belw are ur ffice and financial plicies. Please take a mment t read this in its entirety. If yu require additinal clarificatin, r have questins abut these plicies, please cntact ur ffice and we will happy t assist yu. A cpy will be prvided upn request. Phnes. Telephnes are answered Mnday thru Friday frm 8:00 am t 5:00 pm. Emergencies. Our practice has full-time cverage fr patient emergencies that may ccur after hurs. If a prblem arises during a time when the ffice is clsed, simply call the ffice at (602) and the answering service will cntact the dctr n call. Yur call will be returned in a timely manner. Please nte that rutine prescriptin refills and referrals are nt cnsidered emergencies and will nt be dne after hurs. Prescriptins. All prescriptin refill requests shuld be called in t yur pharmacy. Yur pharmacy will then cntact the ffice if authrizatin is needed. Yur refill requests will be handled by the practice within 24 hurs after yur pharmacy s request is received. Test Results. Shuld yu have any labratry wrk r ther diagnstic testing dne thrugh ur practice, yu will be ntified f the results as sn as they are available. All results must first be reviewed by the prvider. After review, yu will be ntified. Recrds Release. It takes ur ffice 5 business days t prcess medical recrds requests. Medical recrds will be released t any physician upn yur written request and authrizatin as a curtesy. The fee fr nn-treatment medical recrds release is $0.25 per page and payment is required upn release f the medical recrd(s). Frms Cmpletin. Cmpletin f frms fr insurance purpses, such as applicatin fr insurance cverage, disability, r FMLA leave, will be billed t the patient, r representative that requests cmpletin f the frms, at a fee f $30. Telephne Cnsultatins. Our ffice charges fr telephne cnsultatins initiated by the patient r the patient s guardian. Fees are updated in cnjunctin with the Center fr Medicare and Medicaid Services fee schedule updates. Referrals/Authrizatins. Referrals/authrizatins frm yur Primary Care Physician r Insurance Carrier apprving visits t ur ffice, diagnstic facilities, r labs can take several days t retrieve. Yu are required t cntact yur Primary Care Physician (PCP) at least 1 week in advance t ntify them f yur appintment. Failure t d s my result in yur referral/authrizatin being denied by yur PCP and/r insurance cmpany; therefre making yu respnsible fr any and all charges incurred during yur visit. Insurance and Payment Plicies Prf f Insurance. We ask that yu present yur insurance card t us at every visit. If yu fail t prvide us with the crrect insurance infrmatin at each visit, yu may be respnsible fr payment fr all services prvided. Yur health insurance cntract is between yu and yur insurance cmpany. Knwing yur insurance benefits is yur respnsibility. Any questins r cmplaints regarding yur cverage shuld be directed t yur insurance cmpany. We are cntracted with mst insurance plans. If yu are nt insured by a plan we are cntracted with, payment in full is expected at the time f

9 service. If yu are insured by a plan we are cntracted with but dn t have an up-t-date insurance card, payment in full is required until we can verify yur cverage. If yu are uninsured please cntact ur Business Office at (602) ext r 1420 t btain qutes fr impending services. C-Payments/Deductibles. Yur insurance cmpany requires us t cllect c-payments and/r deductibles at the time f service. Waiver f cpayments and/r deductibles may cnstitute fraud under state and federal law and/r the cntract terms f yur insurance cmpany. Please help us in uphlding the law, and cmplying with the cntract terms f yur insurance cmpany, by paying yur c-payment and/r deductible at each visit. Nn-cvered Services. Please be aware that sme r all f the services yu receive may be nn-cvered r nt cnsidered medically necessary by yur insurer. Yu must pay fr these services in full. Claims Submissin. We will submit yur claims and assist yu in any way we reasnably can t help yu get yur claim(s) paid. Yur insurance cmpany may need yu t supply certain infrmatin directly. It is yur respnsibility t prmptly cmply with their request. Accunt Balances. Accunt balances are t be paid in full unless acceptable payment arrangements have been established with ur billing ffice. Payments made t satisfy accunt balance(s) will always be applied t ldest date(s) f service. Unpaid balances ver 90 days will be referred t a cllectin agency and may subsequently prmpt discharge frm this practice. If yu need assistance crdinating payment frm yur insurance cmpany, establishing a payment plan, r have difficulty making yur c-pay r deductible, please cntact the Business Office at (623) ext t speak with the Business Office Manager. Allergy Serum. Patients receiving allergy serum and injectins are generally respnsible fr paying fr sme f their care. The exact amunt is determined by yur insurance plan, and will vary depending n hw much f yur deductible, if any, has been satisfied. It is very difficult t accurately prject yur individual csts in advance f final ntificatin frm yur insurance plan, but we can give general guidelines as fllws: The serum is mixed all at ne time, and generally billed ut during the first visit, with subsequent fees fr the prfessinal cmpnent f administering the medicatin billed ut at each visit. The billed charges fr the serum-nly average $1,600 fr a ne-year supply; mst health plans pay between $800 and $1,000 fr this medicatin. The average allergy injectin patient will have 60 visits ver a ne-year perid f time, and will incur billed charges fr the administratin that average $25 - $30 per visit. Mst health plans pay rughly 50% f these charges, unless there is an alternate c-pay requirement fr allergy injectin visits. If yu have a high deductible health plan and have nt satisfied the deductible limits, yu culd be liable fr the cntracted amunt f the ne-year supply f serum n yur first visit, plus the amunt fr the medical administratin fee, which averages $25 - $30 per visit. On subsequent visits yu wuld be respnsible fr nly the administratin fees, because the serum fees will have already been paid fr the full year.

10 Charge Estimates. Patients and respnsible persns may receive charge estimates fr services. Please remember this is an estimate nly. Final charges are based n physician rders and ttal services prvided. Pre-Registratin. When yu schedule an appintment fr any f ur ffice lcatins yu may be cntacted by ne f ur Pre-Registratin staff t btain and/r verify yur demgraphic and insurance infrmatin prir t yur visit. Prviding this infrmatin will save yu time the day f yur service. The Pre- Registrar will take time t explain yur insurance cverage and any deductibles r c-insurance that may be due frm yu. Dual Custdy f Children. In cases where parents have dual custdy ver a minr child, r where there is a legal dcument assigning rights t ne parent, ur plicy is t assign financial respnsibility t the parent wh authrizes treatment fr the child. This authrizing parent is respnsible fr paying the guarantr s share f the treatment csts. If yu are in this situatin, and there is a legal dcument assigning financial respnsibility t anther party, it is yur respnsibility t make payment arrangements with the ther party in advance f the child s appintment, and t ensure that payment flws thrugh yu t AAAI fr the treatment. Missed Appintments/Cancellatins. A $25 Missed Appintment fee will be assessed fr appintments nt cancelled r rescheduled with a minimum f 24 hurs advance ntice. This fee will be yur respnsibility and billed directly t yu. Please help us t serve yu better by keeping yur regularly scheduled appintment(s). Thank yu fr understanding ur plicies. Please let us knw if yu have any questins r cncerns. I have read and understand the ffice plicies and agree t abide by their guidelines: Signature f Patient r Respnsible Party / / Date

11 Patient N-Shw / Cancellatin Plicy In keeping with ur gal t prvide each patient with the highest standard f care pssible, we ask that yu make every effrt t keep yur scheduled appintments and arrive in a timely manner. N-shws r last minute cancellatins leave empty appintment times fr ther patients in need f medical care. Fr this reasn, a fee f $25 may be impsed fr missed r cancelled appintments with less than 24 hurs ntice. Please nte that n-shw/late cancellatin fees are patient respnsibility and will nt be billed t yur insurance cmpany. Thank yu in advance fr yur cnsideratin and fr allwing us t partner in yur healthcare needs E. Baseline Rd, Suite 201 Gilbert, AZ Fax# W. Ranch Sante Fe Blvd,.Suite A-100 Avndale, AZ Fax# W. Eugie Avenue, Suite 200 Glendale, Arizna Fax East Muntain View, Suite 200 Scttsdale, Arizna FAX