I have requested medical services from Southwest Allergy and Asthma and Dr. Kenneth Pinna on behalf of myself and/or my dependents, and understand that by making this request, I become fully financially responsible for any and all charges incurred in the course of the treatment authorized.

I understand that fees are due and payable on the date that services are rendered and agree to pay all such charges incurred in full immediately unless other payment arrangements have been made in advance.

As a courtesy my insurance company will be billed for payment of the medical services received. If a quote of benefits is provided, I understand that it is not necessarily a guarantee of payment and I am responsible for any amount not covered by insurance, including but not limited to deductible, co insurance, and co pay. If any balance remains after 120 days, the account will be considered delinquent and reviewed for further collection activity.

In the event that the account is assigned to a collection agency, I agree to pay any and all attorney fees, court costs, and a collection agency fee of 33.3%, which will be added to the outstanding balance with or without suit.

I hereby authorize medical treatment and/or procedures to be performed by medical staff employed by Southwest Allergy and Asthma as needed.

I hereby authorize and direct my insurance carrier(s), including Medicare, private insurance and any other health/medical plan, to issue payment check(s) directly to Dr. Kenneth R. Pinna and/or Southwest Allergy and Asthma for medical services rendered to myself and/or my dependents regardless of my insurance benefits, if any.

I understand that as part of my healthcare, Southwest Allergy and Asthma originates and maintains medical records. I understand that this information serves as: (1) A basis for planning my care and treatment (2) A source of information for other health professionals who contribute to my care (3) Proof of diagnosis and procedural information for medical billing purpose.

By signing this form, you consent to our proper use and disclosure of your protected healthcare information and understand the following: (1) The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations (2) The practice is not required to agree to the restrictions requested (3) The right to revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon.

I further understand that Southwest Allergy and Asthma reserves the right to change their notice and practices prior to implementation, in according with Sections 164.520 of the Code of Federal Regulations. Should Southwest Allergy and Asthma change their notice, they will give a revised notice to the patient upon the next office visit.

I understand that by refusing to sign this consent or revoking consent, this organization may refuse to treat me as permitted by Section 164.506 of the Code of Federal Regulations.