Asthma Allergy Center - Girl Sneezing

Patient Form

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Consent for Allergy Testing

Allergy testing consists of multiple scratch testing and/or injections beneath the skin, similar to mosquito bites. The doctor will then read the results of the skin testing. The risk of this type of procedure is minimal, but in rare instances adverse reactions (side effects) can include but are not limited to swelling, skin rashes or difficulty breathing. Our office is equipped to handle these problems should they arise.


I authorize the staff at Asthma & Allergy Center to perform Serial Endpoint Testing (skin testing for allergies) on my child, or I and I understand the risks involved.


I also understand that it is my responsibility for notifying my insurance company before the scheduled tests. Failure to do so may result in nonpayment of insurance benefits. Allergy testing and treatment will be billed by the doctor ordering the testing. Patients with insurance coverage through an HMO are required to contact their primary care physician instead of their insurance carrier to obtain the mandatory referral. PLEASE BRING YOUR REFERRAL prior to or at the time of testing.

When you contact your insurance company, you must ask the following:

1. Is pre certification necessary?

2. Is allergy testing a covered benefit? The most common codes used are 95004, 95024, and 95018.

3. What portion of the total cost of allergy testing will be covered?


All patients will be required to pay your insurance co-pay at the time of testing. I understand the above policies and accept responsibility for the balance not covered by my insurance.


We will have you sign this form electronically in our office at the time of your visit.



Thank you!

Some of the areas we serve are: Carol Stream, West Chicago, Addison, Roselle, Schaumburg, Bloomingdale, Wheaton, Glendale Heights, Wood Dale, Elk Grove Village, Glen Ellyn, Lombard, Hanover Park, Hoffman Estates, Villa Park, Bartlett, Streamwood, Bolingbrook, Warrenville, Naperville, Winfield, Geneva, Downers Grove, North Aurora, Aurora, Lombard, Elmhurst, Inverness, Bensenville, Woodridge, Darien, Medinah, Hinsdale, Oakbrook, Burr Ridge, Lisle, St Charles, Melrose Park, River Forest, Norridge, Elburn, Montgomery, Sugar Grove, Elgin, South Elgin, Westmont, Batavia, Wayne, Itasca, Hillside, Rolling Meadows, Palatine, South Barrington, Barrington, Rosemont, Palatine, Franklin Park, River Grove, Arlington Heights, Mt Prospect, Prospect Heights, Oak Park, Forest Park, Western Springs, LaGrange, Northlake, Countryside, Plainfield, Lemont, Romeoville, Des Plaines, Niles, Park Ridge Indiana and Wisconsin.