Financial Responsibility Agreement

FINANCIAL RESPONSIBILITY AGREEMENT

This Financial Responsibility Agreement (Agreement) is a legally binding contract between you and
Valley Allergy and Asthma Clinic, LLC (VAAC). This Agreement supersedes any and all prior
agreements between VAAC and you concerning payment of our charges and applies to all future
charges you may incur. Please read this document carefully and ask a member of our staff to answer
any questions which you may have before you sign this document.

CHARGES DUE AT THE TIME OF SERVICE: All Charges for our services are due at the time of the
service except as provided in this Agreement. You can access an updated list of service charges on
our website www.matsuallergy.com at any time.

INSURANCE BILLING: If you are insured by a company for which VAAC is a Preferred Provider, we
will bill your insurance company in accordance with our agreement with your insurance company.
Otherwise, we will bill your insurance as a courtesy only, and we reserve the right to stop doing so at
any time. Regardless of if we bill your insurance company, you are ultimately responsible for payment
of all charges.

DEDUCTIBLE: If you know that you have not yet met your full insurance deductible at the time of
service, you must pay the unmet portion of your deductible at that time, and we will bill your insurance
company for the rest of your charges. If we bill your insurance company and any portion of our
charges are not paid by your insurance company due to an unmet deductible, we will bill you for, and
you must pay, such unpaid charges.

COPAYMENTS, COINSURANCE, AND LIMITS ON COVERAGE: Even after you have met your full
deductible, your insurance may not cover 100% of our charges. If you know, or if we believe, that you
have a copayment obligation, or there are applicable limits on your insurance coverage, you must pay
all copayment amounts and any other amounts not covered by your insurance at the time of service,
and we will bill your insurance company for the rest of our charges. If we bill your insurance company
and any portion of the charges are not paid by your insurance company due to a copayment amount
or limit on the coverage, we will bill you for, and you must pay, such unpaid charges.

USUAL AND CUSTOMARY CHARGES: VAAC sets its fees independent of any health insurance
company or other organization. If you are insured by a company for which VAAC is a Preferred
Provider, we have agreed to accept what your insurance company considers usual and customary
charges in payment for our services. If VAAC is not a Preferred Provider for your insurance company,
and if we bill your insurance company and any portion of our charges is not paid by your insurance
company because our charges exceed what your insurance company determines to be usual and
customary, we will bill you for, and you must pay, such unpaid charges.

DUAL COVERAGE: If you have medical insurance from more than one source, VAAC will, as a
courtesy, bill your primary and secondary insurance, but we reserve the right to stop doing so at any
time. We will not bill a third insurance under any circumstance. If we bill your secondary insurance,
the above provisions concerning payment of deductibles, copayments, and other amounts will still
apply. Regardless of whether we bill your secondary insurance, you will remain ultimately responsible
for payment of all our charges.

MOTOR VEHICLE INSURANCE: VAAC will not, in any case, bill a motor vehicle insurance company.
All charges for any care which you receive related to a motor vehicle accident must be paid at the
time of service. VAAC will provide you with the necessary documentation so that you may be
reimbursed by your motor vehicle insurance.

WORKER’S COMPENSATION: VAAC will not, in any case, bill for Worker’s Compensation.

HEALTH SHARES: VAAC will not, in any case, bill a health share plan. All charges for any care
which you receive must be paid at the time of service. VAAC will provide you with the necessary
documentation so that you may be reimbursed by your health share.

AUTHORIZATIONS & PROCEDURES: The decision to perform any medical testing or procedure is
entirely between you and your Provider. However, in each case your insurance company will decide
whether the service is covered by your policy. In the case where your insurance company does not
cover a service, we will bill you for, and you must pay, all the charges for that service. VAAC does not
seek preauthorization from insurance companies unless you request us to do so. Please be warned
that prior authorization is not a guarantee that your insurer will pay for a specific service. You remain
responsible for payment of all our charges in any event.

SERVICE CHARGES: The below listed service charges will not be billed to any medical insurance
company and must always be paid by you directly. Valley Allergy and Asthma Clinic has an
appointment cancellation policy in place to provide the best schedule availability to all patients in
need. Inadequate notice for appointment changes negatively impacts our ability to provide the best
care possible. We require all requests to reschedule a provider appointment be made 2
business days in advance. Any provider appointment CHANGE requests made with less than
2 business days’ notice will result in a mandatory $50.00 rescheduling fee. Any injection suite
appointment CHANGE requests made with less than 24 hours’ notice through our online
booking program will result in an automatic $19.00 charge to your credit card on
file. Rescheduling fees are due before a replacement appointment can be made. Rescheduling fees
will not be billed to insurance and are the sole responsibility of the patient. If 2 or more appointments
are rescheduled with less than 2 business days’ notice, a letter of termination will be sent to the
patient’s address on file. If Medicaid applies to the patient, Valley Allergy and Asthma Clinic has a
legal obligation to report the late cancellation appointment to the State of Alaska Department of
Health and Social Services. Valley Allergy and Asthma Clinic’s staff understand extraordinary
circumstances occur (hospitalizations, deaths, etc.). If you have provided the office with less than 2
business days of notice for a cancellation with a provider and feel you are exempt from termination or
a rescheduling fee, you may provide your situation IN WRITING (We will not accept verbal
requests). Exemption requests will be reviewed within 30 days of submission, and no appointments
are permitted during this time unless the fee is paid in full.

A charge of $30.00 will be applied to checks returned to us due to non-sufficient funds in your bank
account. A one-time courtesy copy of your current medical records (up to 10 pages) will be provided
at no charge upon request. Additional copies (up to 25 pages) will be charged a $25.00 medical
records fee. Any additional pages will be charged $0.50 per page.

A charge of $50.00 or more may be charged for allergen immunotherapy vial transfers and/or
shipments. Valley Allergy and Asthma Clinic is not responsible for the safety of extracts once
they leave our office.

Drugs that are not covered by your insurance and that are administered or obtained in connection
with care, such as albuterol or ipratropium, must be paid by you directly.

Extended appointments or appointments outside of regular business hours may be subject to an

additional $32.00 charge per 15 minutes.

TELEMEDICINE: VAAC may use Telemedicine (Live two-way audio and video, telephone, text,
email, portal) for clinical evaluations. Expected benefits include improved access to care by enabling
you to be seen from home or another location. Risks include but are not limited to; a physician
determining that the telemedicine encounter is not yielding enough information to make an
appropriate clinical decision, which may require additional in-person visits; technology problems may
delay medical evaluation and treatment. You have the right to withdraw consent to the use of
telemedicine at any time. If the physician believes you would be better served by a traditional face-to-
face encounter, the physician may stop the telehealth visit and schedule a face-to-face visit. The laws
that protect privacy and confidentiality of medical information also apply to telemedicine. VAAC does
not seek preauthorization from insurance companies before providing telemedicine services.
Therefore, it is your responsibility to seek prior authorization from your insurance company should
you need or wish to do so. Please be warned that prior authorization is not a guarantee that your
insurer will pay for a specific service. You remain responsible for payment of all our charges in any
event.
CREDIT CARD ON FILE: VAAC is committed to making our billing process as simple and easy as
possible. We require that all patients receiving care in our injection suite provide a credit card on file
with our office. We store your card number in a secure, compliant system. If you do not have
insurance, or have one that we do not bill, we will immediately charge the amount due at the time of
service unless you provide alternate payment. If you have insurance that we bill, we will mail, email or
text your statement after your insurance processes your claim. If you do not pay your balance within
90 days, your account will be sent to collections through Cornerstone Credit Services, LLC.
Notice of Privacy Practices
This notice describes how information about you may be used and disclosed
and how you can get access to this information. Please review it carefully.
Introduction
At Valley Allergy and Asthma Clinic, LLC, we are committed to treating and using protected health
information about you responsibly. This Notice of Health Information Practices describes the personal
information we collect, and how and when we use or disclose that information. It also describes your
rights as they relate to your protected health information. This Notice is effective April 6, 2023, and
applies to all protected health information as defined by federal regulations.

Understanding Your Health Record/Information

Each time you visit Valley Allergy and Asthma Clinic, LLC, a record of your visit is made. Typically,
this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan
for future care or treatment. This information, often referred to as your health or medical record,
serves as a:
Basis for planning your care and treatment, means of communication among the many health
professionals who contribute to your care, legal document describing the care you received,
means by which you or a third-party payer can verify that services billed were actually
provided, a tool in educating health professionals, a source of data for medical research, a
source of information for public health officials charged with improving the health of this state
and the nation, a source of data for our planning and marketing, and a tool with which we can
assess and continually work to improve the care we render and the outcomes we achieve.
Understanding what is in your record and how your health information is used helps you to ensure its
accuracy, better understand who, what, when, where, and why others may access your health
information, and make more informed decisions when authorizing disclosure to others.

Your Health Information Rights

Although your health record is the physical property of Valley Allergy and Asthma Clinic, LLC, the
information belongs to you. You have the right to:
• Obtain a paper copy of this notice of information practices upon request,
• Inspect your health record as provided for in 45 CFR 164.524,
• Obtain a copy of your healthcare records, either on paper or electronically,
• Amend your health record as provided in 45 CFR 164.528,
• Obtain an accounting of disclosures of your health information as provided in 45 CFR 164.528,
• Request communications of your health information by alternative means or at alternative locations,
• Request a restriction on certain uses and disclosures of your information as provided by 45 CFR
164.522, and
• Revoke your authorization to use or disclose health information except to the extent that action has
already been taken.
Our Responsibilities
Valley Allergy and Asthma Clinic, LLC is required to:
• Maintain the privacy of your health information,
• Provide you with this notice as to our legal duties and privacy practices with respect to information
we collect and maintain about you,
• Abide by the terms of this notice,
• Notify you if we are unable to agree to a requested restriction, and
• Accommodate reasonable requests you may have to communicate health information by alternative
means or at alternative locations.
We reserve the right to change our practices and to make the new provisions effective for all
protected health information we maintain. Should our information practices change, upon your
request, we will mail a revised notice to the address you’ve supplied us, or if you agree, we will email
the revised notice to you.
We will not use or disclose your health information without your authorization, except as described in
this notice. We will also discontinue using or disclosing your health information after we have received
a written revocation of the authorization according to the procedures included in the authorization.

For More Information or to Report a Problem

If have questions and would like additional information, you may contact the practice’s Privacy
Contact, Teddi Worrock, at (907) 745-4488.
If you believe your privacy rights have been violated, you can file a complaint with the practice’s
Privacy contact, or with the Office for Civil Rights, U.S. Department of Health and Human Services.
There will be no retaliation for filing a complaint with either the Privacy Officer or the Office for Civil
Rights. The address for the OCR is listed below:
Office for Civil Rights
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Room 509F, HHH Building
Washington, D.C. 20201

Examples of Disclosures for Treatment, Payment, and Health Operations

We will use your health information for treatment.
For example: Information obtained by a nurse, provider, or other member of your health care team
will be recorded in your record and used to determine the course of treatment that should work best
for you. Your provider will document in your record his or her expectations of the members of your
health care team. Members of your healthcare team will then record the actions they took and their
observations. In that way, the provider will know how you are responding to treatment.
We will use your health information for payment.
For example: A bill may be sent to you or a third-party payer. The information on or accompanying
the bill may include information that identifies you, as well as your diagnosis, procedures, and
supplies used. If you choose to pay in full at the time of service for your healthcare, you have the right
to restrict that information from being shared with your insurance company.
We will use your health information for regular health operations.
For example: Members of the medical staff may use information in your health record to assess the
care and outcomes in your case and others like it. This information will then be used to continually
improve the quality and effectiveness of the healthcare and service we provide.
Business Associates: There are some services provided in our organization through contacts with
business associates. Examples include physician services in the emergency department and
radiology and certain laboratory tests. When these services are contracted, we may disclose your
health information to our business associate so that they can perform the job we’ve asked them to do
and bill you or your third-party payer for services rendered. To protect your health information,
however, we require the business associate to appropriately safeguard your information.
Notification: We may use or disclose information to notify or assist in notifying a family member,
personal representative, or another person responsible for your care, your location and general
condition.
Communication with family: Health professionals, using their best judgment, may disclose to a family
member, other relative, close friend or any other person you identify, health information relevant to
that person’s involvement in your care or payment related to your care.
Research: We may disclose information to researchers when an institutional review board that has
reviewed the research proposal and established protocols to ensure the privacy of your health
information has approved their research.
Funeral directors: We may disclose health information to funeral directors consistent with applicable
law to carry out their duties.
Organ procurement organizations: Consistent with applicable law, we may disclose health information
to organ procurement organizations or other entities engaged in the procurement, banking, or
transplantation of organs for the purpose of tissue donation and transplant.
Marketing: We may contact you to provide appointment reminders or information about treatment
alternatives or other health-related benefits and services that may be of interest to you.
Food and Drug Administration (FDA): We may disclose to the FDA health information relative to
adverse events with respect to food, supplements, product and product defects, or post marketing
surveillance information to enable product recalls, repairs, or replacement.
Workers Compensation: We may disclose health information to the extent authorized by and to the
extent necessary to comply with laws relating to workers compensation or other similar programs
established by law.
Public health: As required by law, we may disclose your health information to public health or legal
authorities charged with preventing or controlling disease, injury, or disability.
Law enforcement: We may disclose health information for law enforcement purposes as required by
law or in response to a valid subpoena.
Federal law makes provision for your health information to be released to an appropriate health
oversight agency, public health authority or attorney, provided that a work force member or business
associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated
professional or clinical standards and are potentially endangering one or more patients, workers, or
the public.
 Valley Allergy and Asthma Clinic Consent Page
Please carefully read the following consents, initial beside each section, and sign at the
bottom of this page. If you have any questions or concerns, please discuss these with your
healthcare provider prior to signing.

______ (initial) Financial Responsibility Agreement:

I have read Valley Allergy and Asthma Clinic's Financial Responsibility Agreement and understand its
contents. I acknowledge that I have access to the Financial Responsibility Agreement.

______ (initial) Notice of Privacy Practices:

I have read Valley Allergy and Asthma Clinic's Notice of Privacy Practices and understand its
contents. I acknowledge that I have access to the Notice of Privacy Practices.

______ (initial) Consent for AI Medical Scribe:

I consent to the use of an artificial intelligence (AI) medical scribe to generate clinical notes. I
understand that the AI adheres strictly to HIPAA compliance guidelines for data security. If I have any
questions or concerns regarding the use of AI, I will contact Valley Allergy and Asthma Clinic.

Patient’s Name Patient’s Date of Birth

Patient’s/Parent’s/Legal Guardian’s Signature Today’s Date

Parent’s or Legal Guardian’s Name

 OFFICE USE ONLY
Valley Allergy and Asthma Clinic
Medical History Questionnaire
T V? Y N Date: Past VAAC pt? Y N

Wt Talk? Y N Flu? Personal: Y N

Ht Y N Date: Family: Y N
Today’s D a t e : Beta Blocker? Y N
BP Name(s):
Patient N a m e : Off Antihist? Y N
HR How long?
DOB: Age:
Ox

Medications
What medications do you take on a daily or frequent basis? Please include all prescription and over-the-counter medications to
include sprays, inhalers, and supplements.
Medication Name Dose and Frequency Indication/Start Date

Allergies to Medications
List any allergies to prescribed and/or over the counter medications that you have.
Medication Allergy Type of Reaction Reaction Date

Other Allergies (foods, specific skin products, latex, etc.)

Other Allergies, if any Type of Reaction Reaction Date

Main Reason for Visit (What brings you here?)

Please tell us the main reason you are here today and include any issues you would like to discuss with Dr. Arseneau.

Past Medical and Surgical History

Have you ever been diagnosed with any of the following?

Recurrent Infection COPD/Emphysema Migraines Diabetes

Nasal Polyps Heart Disease Hypertension Swelling(Angioedema)
GERD (reflux) Thyroid Disease Recurrent Hives Cancer

Last Updated 10/13/2023 1 of 3

 Patient Name: DOB:

Have you ever had an appointment with an allergist before? If yes, When? YES NO
Where?

Do you think you may have seasonal or year-round allergies (hay fever)? YES NO
a. If yes, have you been skin tested before? YES NO
b. Have you been on allergy shots before? YES NO
c. What season is problematic for you? Spring Summer Fall Winter
d. Do you have any of the following symptoms?
stuffy nose sneezing itchy red eyes runny nose postnasal drainage
e. What triggers your symptoms?
f. Have you noticed any of these things trigger your symptoms?
perfumes cold or hot temperatures dust smoke
g. When did your symptoms begin?
h. What medications have helped?
i. What medications have not helped

a. Have you ever been diagnosed with eczema? YES NO

b. Regardless of your answer to a. above, do you have other skin concerns? YES NO
c. If yes to either, what do you apply to your skin and how many times daily?

a. Have you ever been diagnosed with asthma? YES NO

b. Regardless of your answer to a. above, have you ever used inhalers? YES NO
c. If yes to either, please mark all that apply below:
☐ Last use of short acting “rescue” inhaler:
☐ Ever had a breathing test
d. Regardless of your answers above, do you regularly have any of the following symptoms?
Please mark all that apply. YES NO

☐ Chest tightness ☐Cough ☐Shortness of breath ☐Wheezing

Have you ever had an adverse reaction to a bee, wasp, hornet, fire ant, or mosquito? YES NO
If yes, when and what happened?

Have you ever had an adverse reaction to food? YES NO

If yes, please specify below the food, date when reaction happened and symptoms.
Food 1 Date Symptoms
Food 2 Date Symptoms
Food 3 Date Symptoms

Have you ever had an adverse reaction to latex? YES NO

For female patients aged 12 to 49: Are you or might you be pregnant? YES NO

Have you ever been hospitalized overnight for reasons other than surgery? If so, please list.

Have you ever had a surgery? If so, when and what type?

Last Updated 10/13/2023 2 of 3

Patient Name: DOB:
Family History
Does anyone in your family have or had any of the conditions below? Please circle.
Allergies Mother Father Brother(s) Sisters(s)
Asthma Mother Father Brother(s) Sisters(s)
Eczema Mother Father Brother(s) Sisters(s)
Food Allergy Mother Father Brother(s) Sisters(s)
Recurrent Swelling Mother Father Brother(s) Sisters(s)
Immune System Problems
Mother Father Brother(s) Sisters(s)
Other: Mother Father Brother(s) Sisters(s)

Social History NOTE: If patient is a child, please answer questions for adult caretakers.
Do or did you ever smoke tobacco? YES NO
a. If yes, how much and how long? pack(s) day or week for years
b. Quit date:
c. If patient is a child, is there exposure to second-hand smoke? YES NO
d. If adult, is there exposure to second-hand smoke? YES NO
e. Do or did you ever vape? YES NO
f. Do you use marijuana? YES NO
If yes, circle the method and timing of use: Method: Vape Smoke Edibles
Timing: Daily Weekly Monthly Occasionally For: years.
What do you do most days of the week, and where? (e.g., public school, daycare, homemaker, office work, construction work, etc.)

Have you ever spent more than two months of your life in an environment that could be considered hazardous to your lungs,
such as chemical or fine particle dust exposure? Please specify. (e.g., mining, chemical plant, construction, auto mechanic, fire fighter)

Environmental History
Do you have or are you around pets? If yes, please indicate how many animals (indoor & outdoor).
Cats ___ Dogs ___ Birds ___ Guinea Pigs ___ Rabbits ___ Horse ___ Other (specify)
Number of years lived in present home?

Review of Systems
Please circle problems you currently have or have frequently had in the past.
General: Fever Chills Unintended weight loss
Night sweats Fatigue Weight gain
Eyes: Itch Pain Excessive tears Dryness
Loss of Vision
Ears/Nose/Throat: Chronic nasal congestion Chronic sinus infection Frequent ear infection Ringing in ear
Ear tubes Hearing loss Dizzy spells Snoring
Sleep apnea Frequent nose bleeds Hoarseness Frequent sore throat
Trouble swallowing Nasal polyps
Lung and Chest: Cough Wheeze Shortness of breath Coughing up blood
Coughing up phlegm
Heart: Chest pain Palpitations Irregular heartbeat Swelling of ankles
Gastrointestinal: Nausea Vomiting Abdominal pain Diarrhea
Constipation Vomiting blood Blood in stool Heartburn
Skin: Hives Rash Itching Swelling
Musculoskeletal: Joint pain Muscle pain or cramps Joint swelling
Genitourinary: Pain/burning urination Frequent urination Blood in urine
Mental Health: Anxiety Depression
Neuro: Headaches Seizures Numbness or tingling

Last Updated 10/13/2023 3 of 3

Valley Allergy and Asthma Clinic
Patient Registration
Name: __________________________________________________________ Date of Birth: _____/_____/______
FIRST MIDDLE LAST

Gender: Female Male Other: ___________________ SSN: ____________________

Race: _______________
Prefer not to answer Prefer not to answer
Ethnicity: ______________ Marital Status: Single Married Divorced Widowed

Mailing Address: _________________________________ City: __________________ State: ______ Zip: _________

Home Address: _________________________________ City: __________________ State: ______ Zip: _________

Cell Phone: _____________________ Home: _____________________ Work: _____________________

Email Address: _________________________________

Emergency Contact Name: ___________________________ Phone: _______________ Relationship: ____________

If the patient is a minor,
Who may authorize treatment for the patient? _________________________________________
Relationship to Patient: ______________________ Phone: _______________________
Who is the financially responsible party? ___________________________________ Date of Birth: ________________
Mailing Address: _________________________________________ Phone: ____________________
Please list anyone who might bring the patient to an appointment, relationship to the patient, and their date of birth.
_________________________________________________________________________________________________
Please list any family members that are seen at Valley Allergy and Asthma Clinic. N/A
_________________________________________________________________________________________________
Preferred Pharmacy and Location (e.g., Fred Meyer in Palmer): ______________________________________________

Who is your Primary Care Provider? _______________________________

I authorize the release of my medical records to the following providers:

_________________________________________________________________________________________________
PRIMARY INSURANCE (Must provide card at check-in)
Insurance Name: ________________________________________ Patient’s Relationship to Subscriber: _____________________
Subscriber’s Name: ______________________________________ Subscriber’s Date of Birth: _____/_____/______
Member ID: ____________________ Group #: ____________________ Subscriber’s SSN: ___________________
SECONDARY INSURANCE (Must provide card at check-in)
Insurance Name: ________________________________________ Patient’s Relationship to Subscriber: _____________________
Subscriber’s Name: ______________________________________ Subscriber’s Date of Birth: _____/_____/______
Member ID: ____________________ Group #: ____________________ Subscriber’s SSN: ___________________
I authorize this office to release to the named insurance company any information necessary to expedite insurance reimbursement. I
understand that I am responsible for all charges regardless of insurance coverage.
I acknowledge that I have access to the Notice of Privacy Practices.
By providing my email address and phone number above, I authorize this office to communicate with me via mobile phone, messages,
email, and any kind of electronic communications provided that these communications comply with privacy regulations.

_________________________________________________ __________________________________
Patient’s or Parent’s/Legal Guardian’s Signature Today’s Date