Patient Information

Patient Name*

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Address*

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Phone*

Email*

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DOB*

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Accepted file types: jpg, png, pdf, tif, jpeg, Max. file size: 10 MB.

Do you have insurance coverage?*

Yes

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Name of Your Primary Insurance Plan*

Policy/Member/ID# as it appears on the front of your card.*

Group # (if available)

Do you have secondary insurance?*

Yes

No

Name of Your Secondary Insurance Plan*

Policy/Member/ID# as it appears on the front of your card.*

Group # (if available)

Upload a front and back picture of your insurance card(s)

Please make sure to upload both the front and back of the card to ensure accurate information. If you are a self-pay patient you can ignore this. Please note, payment is due in full at the time of check in.

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Accepted file types: jpg, png, pdf, tif, jpeg, Max. file size: 10 MB.

If I do not have insurance I understand I will be considered 'Self-Pay' and responsible for balance payment at the time services are rendered. I further understand that if at any time I elect insurance coverage, during my treatment with Raffi Tachdjian MD Inc, and wish to bill to my insurance, I must provide a copy of my insurance card.

Relation to the Patient*

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Date of Birth*

How were you referred to us?*

My Physician

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Medication History

Are you taking any medications, supplements or vitamins?*

Yes

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What are your current medications?*

Name

Dosage

Frequency

Date/Year started

Preferred Pharmacy*

Type none if you don't have a preferred pharmacy.

Pharmacy Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Raffi Tachdjan, MD HIPPA Privacy Practice

The HIPAA privacy law gives individuals the right to request restriction on users and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that communication of PHI be made by alternative means.

Please read and mark those forms of communication listed below that you personally approve for disclosure and discussion of protected health information. Please put a checkmark on all the contact boxes with your preferences.

You can view our full HIPPA Disclosure Statement by clicking here.

Please make sure to read the information above.*

Please check this box that you have read the above statement

Signature*

Authorization for Telemedicine Visit

CONSENT TO USE TELEMEDICINE

I am physically located in California. At the beginning of each telemedicine session, I will help my doctor to complete a check-in to assess the suitability of using telemedicine services by verifying my full name, my current location, my readiness to proceed, and whether I am in a situation conducive to private, uninterrupted communication. By signing this consent, I understand and agree:

My doctor is located in and licensed by the State of California. My doctor may not be able to prescribe medications for me and/or may not be able to assist me in an emergency situation when I am located in any other state or country. If I require medication, I may contact my doctor. If I require emergency care, I may call 911 or proceed to the nearest hospital emergency room for help. If I am having suicidal thoughts or making plans to harm myself, I can call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255) for free 24-hour hotline support.
I submit to the exclusive jurisdiction of the California state superior courts and agree that any claim, lawsuit, or other legal proceeding arising out of or relating to the telemedicine services provided by my doctor and my doctor’s staff will be brought solely and exclusively in California state superior courts. I also agree that the interpretation of this consent will be exclusively governed by and construed in accordance with the laws of California.
My doctor believes that telemedicine services are appropriate for my medical condition and that I would benefit from its use despite its risks and limitations. While I may expect anticipated benefits from the use of telemedicine, no specific results can be guaranteed or assured.
If my doctor believes at any time that another form of services (for example, a traditional in-person consultation) would be appropriate, my doctor may discontinue telemedicine services and schedule an in-person consultation with my doctor or refer me to a healthcare provider in my area who can provide such services.
I have the right to withdraw consent to the use of telemedicine services at any time and receive inperson healthcare services with my doctor.
I received an explanation of how the electronic communications technology will be used for the telemedicine services. I am comfortable with using electronic communications technology to communicate with my doctor and understand there are limitations to the technology which may require an in-person consultation.
I agree to have the necessary computer, equipment and internet access for my telemedicine communications. I also agree to arrange for a location with sufficient lighting and privacy and is free from distractions and intrusions during my telemedicine communications.
The laws that protect privacy and the confidentiality of my medical information also apply to telemedicine. The medical information that is transmitted electronically by my doctor to me will be encrypted during transmission and will be stored only by my doctor or a service provider selected by my doctor. I understand the dissemination of any personally-identifiable images or information from the telemedicine communication to researchers or other healthcare providers will not occur except as required by federal or California state law.
I understand my risks of a privacy violation increase substantially when I enter information on a public access computer, use a computer that is on a shared network, allow a computer to “autoremember” usernames and passwords, or use my work computer for personal communications. I also understand it is my responsibility to encrypt medical information I transmit electronically to my doctor and my failure to use technical safeguards, such as encryption, increases my risks of a privacy violation.
[I agree to be videotaped and recorded during the telemedicine services. I understand the resulting images and audio will become part of my medical record.] OR [No part of the encounter will be recorded without my written consent.]
I have the right to access my medical information and obtain copies of my medical records in accordance with California law.
I understand that the telemedicine services provided to me will be billed to my health insurance company and that I will be billed for any patient responsibility as per my insurance.

I read and understand the information provided in this Consent to Use of Telemedicine. I discussed any questions I had with my doctor and all of my questions were answered to my satisfaction.

Doctor's Name*

First Last

Signature*

Raffi Tachdjan, MD FINANCIAL POLICY AND CONSENT FOR DISCLOSURE

Insurance and Payment: I understand that I am financially responsible for the payment for any services provided and that the submission of any claim to my insurance plan is a courtesy to me by Raffi Tachdjian MD. I acknowledge that I have confirmed with my insurance plan what coverage and benefits I am entitled to for allergy/immunology specialist, (including in-network vs. out-of-network benefits). I further understand that it is my responsibility to continue to verify such coverage prior to each visit to ensure I am aware of any changes. If I am unable to provide proof of insurance, I understand and agree that I will be considered a “cash” patient and responsible for full payment at the time of service.

Co-payments, Co-insurances, Deductibles, Non-covered Services: I understand that Raffi Tachdjan, MD may or may not have a contract with my insurance plan. In order to determine whether Raffi Tachdjan, MD is a contracted (in-network) provider, I agree it is my responsibility to contact my insurance carrier and ask if Raffi Tachdjan, MD, located at 1301 20th Street, Suite #380, Santa Monica, CA 90404 is a contracted provider. I further understand that Raffi Tachdjan, MD inc. may be required to bill me for any applicable co-payments, co-insurances, Deductibles, or Non-covered Services as directed by my insurance plan. I understand that Raffi Tachdjan, MD has a legal and contractual obligation to bill me these items and may not be permitted to adjust and/or waive any amounts owed by me. Such adjustment or waiver is not permitted by Raffi Tachdjan, MD, and would be in direct violation of Raffi Tachdjan, MD’s contracts with such insurance plans and could jeopardize Raffi Tachdjan, MD’s, and the physician’s participating provider status.

Payments Collected at the Time of Service: Because many PPO insurance plans have annual deductibles and Raffi Tachdjan, MD cannot verify if such deductibles have been met, I understand that Raffi Tachdjan, MD will require payment from me at the time of my visit (see below).I understand that if I have an HMO plan, I must have a properly documented referral/authorization by my insurance before receiving services. Not providing such information at the time of my appointment will result in you being classified as a “cash pay” payment and full payment will be required prior to the provision of services.

Cancellation Policy: Due to being a small office, we maintain a strict cancellation policy. If an appointment is not canceled more than 24 hours in advance, it prevents other patients from waiting to be scheduled for an appointment. Because of this, cancellation within 24 hours (or no-show) of your appointment will be subject to a charge of fifty dollars ($50) to the card number provided below; this charge will not be covered by your insurance company.

I understand that if I hold PPO/EPO insurance, or am SELF-PAY status (Medicare and IPA patients excluded), I am financially responsible for the payment of the listed services below.

X-RAYS and LABS: I understand that any radiology (x-rays), and/or blood work ordered by the physician will not be performed in the Raffi Tachdjan, MD office, and I will be referred to an outside non-affiliated facility which I may go to, or, may choose another provider of my choice. I understand that while these tests may be ordered by the physician, it is my responsibility to understand my insurance coverage for these services.

In-Office Testing (e.g. Skin Testing): If you have a deductible for any testing performed by Raffi Tachdjan, MD in its office, such as skin testing (including patch testing), the office will collect your deductible payment at the time of testing.

Other Non-covered Services: Please understand the services below are considered courtesy services and will not be covered by your insurance, and are therefore subject to a $20.00 fee paid upfront by credit card on file:

Medical Letters of Necessity (e.g. Travel letters, apartment/housing, special circumstances, etc.)
School/Summer Camp Forms (*exceptions include same-day school absence form)
Personal copies of medical records (2+ pages)
Retroactive Claim Letters for Laboratory or Imaging Services (*as these are separate business entities from Aire Medical of LA)
Transfer of Antigen Serums to an outside allergist (*subject to a shipping and handling fee starting from $100.00)

Please make sure to read the information above.*

Please check this box that you have read the above statement

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New Patient History Ted

Patient Information

Reason for Your Visit

Environmental History

Medication History

Raffi Tachdjan, MD HIPPA Privacy Practice

Raffi Tachdjan, MD Patient Preference for Disclosure of Personal Medical Information

Authorization for Telemedicine Visit

Raffi Tachdjan, MD FINANCIAL POLICY AND CONSENT FOR DISCLOSURE

I understand that if I hold PPO/EPO insurance, or am SELF-PAY status (Medicare and IPA patients excluded), I am financially responsible for the payment of the listed services below.

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