Patient Information
COVID-19 alert
CORONAVIRUS DISEASE (COVID-19) - UNITED STATES
OUR OFFICE IS TAKING SERIOUS PRECAUTIONS TO HELP LIMIT THE SPREAD OF COVID-19 OUT OF RESPECT FOR OUR IMMUNOCOMPROMISED PATIENTS, WE REQUIRE THAT EVERYONE WEAR A MASK WHEN COMING INTO OUR OFFICE.
EVERYONE'S TEMPERATURE WILL BE TAKEN BEFORE ENTERING OUR CLINIC. YOU WILL BE ASKED TO FILL OUT A COVID-19 QUESTIONNAIRE.
IF YOU HAVE ANY SYMPTOMS OF COVID-19 OR HAVE RECENTLY TRAVELED OUT OF THE AREA, PLEASE CALL OUR OFFICE @208-529-9292.

Patient Information

IDAHO ALLERGY AND ASTHMA CLINIC

Patient Information

Primary Insurance

Person Financially Responsible for Account

Additional Insurance

Assignment and Release

If patient is a minor (under 18 years of age) I authorize

to act in my behalf to make decisions for my child’s personal care, health care and procedures.



I certify that I, and/or my dependent(s), have insurance coverage with

and assign directly to IDAHO ALLERGY AND ASTHMA CLINIC all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by Insurance. I authorize the use of my signature on all insurance submissions.

Terms and Conditions

  1. I agree to pay at the time of service, unless arrangements have been made in advance with our accounting department.
  2. I agree that my/my dependent medical records can be released to referring/personal physician or for billing.

All information provided is accurate to the best of my ability. I/we have read and understand the above terms and conditions. I/we agree to pay all collection costs and/or reasonable attorney fees if any delinquent balance is placed with an agency or attorney for collection or suit.



I certify that I, and/or my dependent(s), have insurance coverage with

and assign directly to IDAHO ALLERGY AND ASTHMA CLINIC all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by Insurance. I authorize the use of my signature on all insurance submissions.

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