Allergy Serum Order Form

* = required

Order Information

Mail to

Has your insurance changed?

It is your responsibility to make us aware of any changes in your insurance. If yes, please fax a copy of your card, front and back, to: Reception Desk - Fax Number 812-949-3592

Payment

NOTICE: AFTER SUBMITTING THIS REQUEST THERE WILL BE INSTRUCTIONS FOR PAYMENT.

Terms

By completing and submitting this form electronically you are agreeing to be responsible for the payment of the serum ordered. Due to insurance guidelines, all serum will be mailed. No serum will be available for pick-up. All information gathered in this order will be strictly confidential and for the sole purchase of purchasing serum. Advanced ENT & Allergy will not share this information with any outside parties for any reason other than for the purpose of collections or in the case of a subpoena.

Please note that your provider’s HIPAA privacy policies (contact your provider for a copy of its Notice of Privacy Practices) may also apply to information you disclose on this form.
DO NOT USE THIS FORM FOR URGENT MATTERS. IF YOU ARE HAVING AN EMERGENCY, DIAL 911.