Patient Information · Medical services provided by Allergy Partners, P.A. New Patient Medical...

Medical services provided by Allergy Partners, P.A.

Patient Information

First ______________________________ MI________ Last__________________________________ Pt.ID #________________

Prefers to be called_______________ Date of Birth ____/_____/______ Age ____ Marital Status: ____________________________

Married/ Single/Divorced/Widowed/Other

Address Primary _______________________________ City _______________________________ State_____ Zip _____________

Alternate Address ______________________________ City ________________________________ State_____ Zip ____________

Phone #1 _________________________ Phone #2 ________________________ Phone #3 _____________________ Home/Cell/ Work Home/Cell/ Work Home/Cell/ Work

Email address __________________________ Preferred method of contact: Letter Phone call Email Other______________

Sex____ SS # ___________________Referring Physician _______________________Primary Care Physician__________________ M F

Preferred Language ___________ Race: _________Ethnicity: _______________________________________________________

Non-Hispanic or Latino/ Hispanic or Latino/ other or Undetermined

Referred by: Physician Self Family/Friend Internet Yellow pages Radio TV Other ____________________________

Occupation_________________________Employer___________________________Is this visit related to a work injury? Y N

Current Pharmacy Name and Location ____________________________________________________________________________

Emergency Contact

Name _______________________ Phone # ______________________ Relationship to patient______________

Responsible Party/Guardian/Guarantor Address Same as Patient

Name__________________________ Address______________________ ______ City________________ State ___ __Zip________

Home# ________________________ Cell # ________________________________ Business # _________________________

SS#___________________________ Patient’s Relationship to Guarantor________________________ DOB ____/____/____ ____

Sex _______ Occupation_________________________________ Employer _____________________________________________

Primary Insurance Information Address Same as Patient

Name of Ins.Co. _______________ ID # _______________________________Group #______________Group Name____________

Policy Holder Name ______________________________DOB ____/____/______Relationship to Patient _____________ _________

Address_______________________ ___ City________________ State_____ Zip________ Phone #___________________________

SS# ______________________ Sex______ Occupation_____________________ Employer _________________________________

Secondary Insurance Information Address Same as Patient

Name of Ins.Co. _______________ID # ______________________________Group# _______________Group Name ____________

Policy Holder Name ______________________________ DOB ____/____/_______Relationship to Patient_____________________

Address____________________________City________________ State. ______Zip_______Phone# __________________________

SS# _______________________Sex_____Occupation____________________Employer____________________________________

List Any Persons to Whom You Will Allow Access of Your Medical Records

Name/Relationship___________________________________Name/Relationship_______________________________________

I hereby authorize the office of Allergy Partners, P.A .to release any information necessary to process any insurance claim for services rendered. I

hereby authorize payment from my insurance company or governmental payor to pay directly to Allergy Partners, P.A. for services rendered.

Regardless of my insurance benefits, if any, I understand that I am financially responsible for the fees for services rendered.

I acknowledge that I have received a copy of Allergy Partners, P.A. Notice regarding Privacy of Personal Health Information (PHI). I understand that

Allergy Partners, P.A. may request a medication history from my pharmacy as part of my treatment plan, and I hereby give my consent for such

requests.

Signature _____________________________Signature_________________________ Date_______________

Patient Responsible Party


Acknowledgement of HIPAA Privacy Notice and Designation of Disclosure 1. Acknowledgement of Practice’s Notice of HIPAA Privacy. The Notice regarding Privacy of Personal Health Information has

been made available to me. Various copies have been placed in black binders around the waiting room and a copy would be

made for me if I request one.

2. Designation of Certain Relatives, Close Friends and Other Caregivers

a. I agree that the practice may disclose certain of my health information to a family member, close personal friend or

other caregiver, since such person is involved with my health care or payment relating to my health care. In that

case, the Physician Practice will disclose only information that is directly relevant to the person’s involvement with

my health care or payment relating to my health care.

b. I wish to be contacted in the following manner (check all that apply):

Telephone, Written and Fax Communication to Relay Laboratory Results

Home Telephone Number__________________________ Written Communication_____________________

______OK to leave a message with detailed information _____OK to mail to my home address

______OK to leave message/report on Answering Machine _____OK to mail to my office address

______Leave message with a call back number _____OK to fax to this number

c. The following person(s) are not authorized to receive my Patient Health Information:

Print Name_______________________________Relationship________________________

3. We perform medical research at Allergy Partners. Our clinical researchers may look at your health records as part of your

current care or to prepare or perform research. All patient research conducted by us goes through a special process required

by law that review protections for patients involved in research, including privacy. We will not use your health information

or disclose it outside of the practice for research reasons without either getting your prior written approval or determining that

you privacy is protected. Your signature below gives us permission to contact you to discuss possible participation in clinical

research studies.

Signature _____________________________Signature_________________________ Date_______________ Patient/Parent/Guardian Responsible Party

For any patient above the age of 18, still living at home or at college, may we discuss your appointments/treatment/insurance

matters with your parent(s) or guardian?


Patient/Parent/Guardian Responsible Party

I may revoke my consent in writing except to the extent that the practice has already made disclosure in reliance upon my

prior consent. I have read and understand the guidelines of this practice.


Patient/Parent/Guardian Responsible Party

Allergy Partners provides translation and interpreting services to anyone that needs them.


New Patient Medical History and Allergy Survey

Please complete this form. It is important for your doctor to know the details about your medical history and allergy symptoms. If you

have any questions about completing this form; please ask the medical office staff.

Name: ____________________________________________ Age _____________ Date _______________

Primary Care Physician’s Name: _______________________________________________

Referring Physician’s Name: __________________________________________________

Chief complaint(s) and onset:

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

Expectations from this allergy/immunology consultation: _______________________________________________________

________________________________________________________________________________________________________

Do you have any of the following: Asthma Yes____ No____ Uncertain____ Date of Onset________

Exercise induced asthma Yes____ No____ Uncertain____ Date of Onset________

Allergies/hayfever Yes____ No____ Uncertain____ Date of Onset________

Hives/Urticaria Yes____ No____ Uncertain____ Date of Onset________

Rash Yes____ No____ Uncertain____ Date of Onset________

Eczema Yes____ No____ Uncertain____ Date of Onset________

Food allergy Yes____ No____ Uncertain____ Date of Onset________

Drug allergy Yes____ No____ Uncertain____ Date of Onset________

Insect allergy Yes____ No____ Uncertain____ Date of Onset________

Headache Yes____ No____ Uncertain____ Date of Onset________

Anaphylactic reaction Yes____ No____ Uncertain____ Date of Onset________

Other (please describe):

_______________________________________________________________________________________________

_______________________________________________________________________________________________

Allergy evaluation: Have you ever been evaluated by an allergist/immunologist? Yes_____ No_____

Name of previous allergist:_____________________ Date last seen:________________

City/State of previous allergist:_______________________

Have you had any “blood work” to determine if you have allergies? Yes____ No____

Have you ever been “skin tested” to evaluate allergies? Yes_____ No_____ Uncertain______

If “yes”, what were you allergic to (check all that apply):

Trees____ Grasses____ Weeds____ Cat____ Dog____ Dust mites____ Molds____

Cockroaches____ Food____

Have you ever been on “allergy injections/immunotherapy”? Yes_____ No_____ Uncertain_____

If “yes”: When did you start:________________

How long did you receive immunotherapy?________________

Did you find it beneficial? Yes_____ No_____ Uncertain_____

Did you have any significant reactions after injections: No___ Yes___ Describe:________________

Nasal and Eye Allergy Symptoms: Onset of Allergy symptoms (age): _____________

How long have you lived in Las Vegas/Henderson? ______________________

Where have you previously lived? _____________________________________________________________________

Do you have daily symptoms: Yes ____ No _____ Seasonal ______

Are your allergy symptoms getting worse: Yes _____ No ______ Constant_____

What time of year are your allergy symptoms worse (check all that apply):

Spring _____ Summer _____ Fall _____ Winter _____


Do any particular exposures make your allergies worse (check all that apply):

Cats ____ Dogs ____ Smoke ____ Grass ____ Perfume _____ Strong odors _____

Other allergy triggers: _______________________________________________________________

How is your sense of smell: Excellent____ Good____ Poor____ None____

Do you have discolored nasal discharge? Yes____ No____

If yes, what color and how long have you had it? Color:__________ Onset:__________

Check all allergy symptoms that you have:

Eyes: Itching___ Swelling___ Burning ___ Runny ___ Watery___ Discharge___ Pain___

Ears: Itching___ Fullness___ Popping___ Decreased hearing___ Pain___

Nose: Itching___ Sneezing___ Runny nose___ Congestion___ Stuffy nose___ Obstruction___

Mouth breathing___ Nasal pressure or pain___ Nasal polyps___

Throat: Itching___ Soreness___ Post nasal drip___ Throat clearing___ Swelling___

How many times in a row do you sneeze?___________

Do you currently use a nasal spray? Yes____ No____ Name:________________________

Do you currently use an antihistamine? Yes____ No____ Name:_____________________

Do you ever use nasal saline spray? Yes_____ No_____ Never_____

Do you use nasal saline irrigation? Yes_____ No_____ Never_____

Do you use “Afrin” or other over the counter nasal decongestant spray? Yes___ No___ If “yes”, for how long:________

Have you ever had a CT (CAT scan) of your sinuses? Yes____ No____

If “yes”, Date/results:____________________________________________________

Have you ever had sinus surgery? Yes_____ No_____ If “yes”, when:__________________

Have you been evaluated by an ENT/Otolaryngolagist? Yes___ No___ If “yes”, who and when:__________________

Respiratory: Do you cough? Yes____ No ____ Onset of cough: _______________

Do you wheeze? Yes___ No____ Onset of wheezing:_____________

Have you ever been diagnosed with any of the following:

Asthma: Yes_____ No_____ Age of diagnosis:_____________

COPD: Yes_____ No_____ Age of diagnosis:_____________

Emphysema: Yes_____ No_____ Age of diagnosis:_____________

Pneumonia: Yes_____ No_____ How many times:______ Age of diagnosis:____________

Bronchitis: Yes_____ No_____ Age of diagnosis:_____________

Do you cough at night? Yes_____ No_____ How many times per month:____________

Do you wheeze at night? Yes_____ No_____ How many times per month:____________

Do you cough with activity? Yes_____ No_____ How many times per month:____________

Do you wheeze with activity? Yes_____ No_____ How many times per month:____________

What activities cause you to cough or wheeze (check all that apply):

Walking___ Walking up stairs___ Running___ Exercise___

Do you cough when you laugh? Yes_____ No_____

Have you had a chest X-ray? Yes____ No____ Date/results:________________________________

Have you had a chest CAT Scan? Yes____ No____ Date/results:____________________________

Have you had lung function testing? Yes____ No____ Date/results:__________________________

Do you currently use “Albuterol”? Yes____ No____ Nebulizer____ Meter dose inhaler_____

How many times per week do you use Albuterol?_________

Do you use any other respiratory medications? Yes____ No____

Have you used any of the following medications (check all that apply):

Advair___ Flovent___ Pulmicort___ Asmanex___ Qvar___ Foradil___ Serevent___ Combivent___ Singulair___

Albuterol___Dulera___Symbicort___Alvesco___Xoponex

If “yes”, did any of the medications help your breathing: Yes___ No___ Uncertain___

Which medications helped you the most (check all that apply): Advair___ Flovent___ Pulmicort___ Asmanex___ Qvar___

Foradil___ Serevent___ Combivent___ Singulair___ Albuterol___ Dulera___Symbicort___Alvesco___Xoponex

What triggers your respiratory symptoms (check all that apply):

Upper respiratory infection____ Change in weather___ Exercise___ Cold weather___

Hot weather___ Wind___ Smoke___ Strong odors____ Perfume____ Work related____

Have you ever been intubated or on a ventilator? Yes____ No____

Have you ever been admitted to the ICU or PICU? Yes____ No____

How many times in your life have you been on oral steroids:___________

When was your last course of oral steroids:_________

Have you ever had a “Bone density” study? Yes____ No____

Do you have osteopenia? Yes____ No____ Do you have osteoporosis? Yes____ No____

Do you use a peak flow meter? Yes___ No___ If “yes”, what is your best peak flow (liters/min):_____________


Eczema: Have you ever been diagnosed with eczema? Yes____ No____ (If “No”, go to next section)

Age at onset of eczema? ___________

Triggers of eczema (check all that apply):

Food allergy____ Milk____ Egg____ Nut____ Cat____ Dog____ Dry weather____ Cold weather____

Grass exposure____ Swimming pool____ Bathing____ Other:_____________________________

Do you use daily moisturizer? Yes______ No______

Do you use a topical steroid? Yes____ No____

Have you ever had a severe skin infection requiring antibiotics? Yes____ No____ How many times? ________

Do you have a dermatologist? Yes_____ No_____ Name of physician:________________________________

Have you been evaluated for food allergy? Yes____ No____

Rash: (If NO rash, don’t complete this section) When did your rash first start?_______________________________________________________________________

On what part of your body did your rash first appear? ____________________________________________________

Has your rash got: Better____ Worse____ No change_____

Does your rash “come and go”? Yes____ No____ Constant______

Describe the circumstances surrounding the onset of your rash:_____________________________________________

What do you think caused your rash? __________________________________________________________________

Does the rash itch: Yes ____ No____ Uncertain_____

What size are the individual rash lesions? ______________________________________________________________

What time of day is your rash worse? AM_____ PM_____ No difference_________

I s there any pattern or cycle that your rash follows? No____ Yes____ Describe:_________________________________

Have you identified any place where your rash is worse? (check all that apply):

Indoors___ Outdoors___ Home___ Work___ School___ Vacation___ No difference___ Other:____________ What medications have

you used to control your rash:

1._______________________________________ Effective____ Not effective____



4.Steroids:________________________________ Effective____ Not effective____

Do any of the following factors trigger your rash or make it worse? (check all that apply)

Aspirin___ Alcohol___ Food___ Cold___ Heat___ Hot bath___ Water___ Exercise___ Emotions___

Sunlight___ Exertion___ Sweating___ Vibration___ Medication___ Metal exposure___ Tight clothes___

Have you had any of the following symptoms associated with your rash? (check all that apply)

Excessive sweating___ Diarrhea___ Headaches___ Abdominal cramps___ Fever___ Muscle pains___

Joint swelling___ Joint pain___ Joint stiffness___ Fatigue___

Have you traveled outside of the United States immediately prior to onset of the rash? No____ Yes____ Where:_________

Did you start any new medications prior to the onset of the rash? No___ Yes___ Medication:________________________

Drug Allergy: If “no known drug allergies”, place check next to none and proceed to next section: None_______

Please list all drug allergies, date, and reaction(s)

1.Drug: ________________ Date/Age:_________ Reaction:__________________________







Food Allergy: If “no known food allergies”, place check next to none and proceed to next section: None_______

Please list all food allergies, date, and reaction(s)

1.Food: ________________ Date/Age:_________ Reaction:__________________________








Do you have an EpiPen or EpiPen Jr? Yes____ No____

Have you ever used your EpiPen or received Epinephrine? Yes____ No____ Uncertain ____

Have you ever been seen in the emergency room for food allergy? Yes____ No_____

Are you familiar with the Food Allergy and Anaphylaxis Network? Yes____ No____

Insect Allergy: Have you ever had a “life threatening reaction” to a stinging insect? Yes_____ No_____

If “No”, proceed to the next section, otherwise:

If “yes”: Date_________ Suspected insect______________ Reaction______________________

Date_________ Suspected insect______________ Reaction______________________

Date_________ Suspected insect______________ Reaction______________________

Do you have an EpiPen or EpiPen Jr? Yes____ No____

Have you ever used your EpiPen or received epinephrine? Yes____ No____ Uncertain____

Have you ever been seen in the Emergency Room for insect allergy: Yes____ No____

Have you ever been on “immunotherapy” for insect allergy? Yes____ No____ Uncertain____

Environmental History: Do you live in a: House____ Condo____ Apartment____ Mobile Home____ RV____ Assisted living____ Other_________

Do you have any pets? Yes____ No____

If “yes”, how many of the following: Cats_____ Dogs_____ Hamsters____ Ferrets____ Birds____ Snakes____

Are the pets allowed inside the bedroom? Yes____ No____

Do you have carpeting in the bedroom? Yes____ No____

Do you use a humidifier? Yes____ No____ Do you use central air conditioning? Yes____ No____

Do you use a HEPA filter? Yes____ No____ Do you use an “Ionic Breeze” or similar? Yes____ No____

How many people live with the patient (number): __________

Who lives with the patient (i.e. mom, dad, wife, etc.): _________________________________________________________

Does anyone who lives with the patient smoke? Yes____ No____

Does anyone smoke in the house? Yes____ No____ Does anyone smoke in the car? Yes____ No____

Birth History: (Only to be completed if the patient is < 10 years old)

Place of birth (city/state):______________________________________

Full term: Yes____ No____ If “No”, how many gestational weeks:____________

Check type of birth: Vaginal birth ________ OR C-Section __________

Birth Weight: _____________

Did the baby stay in the NICU? No_____ Yes_____ If “yes”, for how long?: __________ Ventilator? Yes____ No____

Complications: No ____ Yes____ If “Yes”, please describe:____________________________________________

Breast fed: Yes___ No___ If “yes”, for how long:______________________________________

Formula type: Cow’s milk based____ Soy___ Lactose Free___ Nutramigen___ Alimentum___ Other________________

Age started solid foods:_________________

MEDICATIONS Please list all current medications and reason for taking:

1.___________________________________ Reason for taking: ____________________________________________









10.__________________________________ Reason for taking: ____________________________________________

Please list all over the counter and herbal/vitamins that you are taking:







PAST MEDICAL HISTORY Operations/Surgery (Name and date of procedure)

1.___________________________________________________________________________

2.___________________________________________________________________________

3.___________________________________________________________________________

4.____________________________________________________________________________

5.___________________________________________________________________________

Hospitalizations (Where, reason, date, and length of stay)

1.____________________________________________________________________________

2.____________________________________________________________________________

3.____________________________________________________________________________

4.____________________________________________________________________________

5.____________________________________________________________________________

Medical Problems (Problem and date diagnosed)

1.____________________________________________________________________________

2.____________________________________________________________________________

3.____________________________________________________________________________

4.____________________________________________________________________________

5.____________________________________________________________________________

6.____________________________________________________________________________

7.____________________________________________________________________________

8.____________________________________________________________________________

9.____________________________________________________________________________

10.____________________________________________________________________________

Immunizations: Are your immunizations up to date? Yes____ No____

Have you had a recent influenza vaccine? Yes___ No____ Date of last dose: _____________

Have you had a Pneumovax / Prevnar (Pneumonia) vaccine? Yes____ No____ Date of last dose:__________

Date of last tetanus vaccine: _________________

Social History: (Adults and adolescents) Do you smoke (check all that apply)? Yes____ No____ Never_____ Quit ______

If “yes”, how much do you smoke? __________ packs per day Age started:____________

If you “Quit”, when did you quit? __________ How many years did you smoke? _______

How many packs did you smoke per day (average)?_____________

Are you exposed to “passive smoke” from another household member? Yes___ No___

Do you drink alcohol? Yes____ No____

Average drinks per day: ____________ Type of alcohol: Beer___ Wine___ Liquor___

Do you use “recreational drugs”? Yes___ No___ If “yes”, what type:______________________________________

Do you consider yourself at “high risk” for HIV? No___ Yes___ If “yes”, why:________________________________

Have you ever had a blood transfusion? No___ Yes___ If “yes”, why:________________________________________

Caffeine use (drinks/day):____________

Exercise (times/week): ______________ Type of exercise:________________________________________________

Seatbelt use (%): 100___ 75___ 50___ 25___ Never___

Sun exposure: Frequently___ Occasionally___ Rarely___

Sunscreen use: Frequently___ Occasionally___ Rarely___

Occupation:___________________________________

Exposure to toxic or noxious chemical/substances: No____ Yes____ Describe:__________________________

Social History: (If < 13 years old) Is the patient exposed to “passive smoke” from another household member? Yes___ No___

Seatbelt use (%): 100___ 75___ 50___ 25___ Never___

Sun exposure: Frequently___ Occasionally___ Rarely___

Sunscreen use: Frequently___ Occasionally___ Rarely___

Blood transfusion? No___ Yes___ If “yes”, why: ________________________________________

Daycare: Yes____ No____ If “yes”, age started attending: ____________________________

School: Yes____ No____ Grade:____________ Performance: Excellent___ Good___ Fair___ Poor___


Immunology Evaluation: Have you ever been diagnosed with a primary immunodeficiency? No___ Yes___ If “yes”, please describe:

_______________________________________________________________

Have any family members ever been diagnosed with an immunodeficiency? No___ Yes___

If “yes”, please describe: _______________________________________________________________

Have you ever been diagnosed with any of the following: (check all that apply)

Pneumonia___ Meningitis___ Osteomyelitis___ Sepsis___ Severe Skin Infection___ Bronchiectasis___

Cystic Fibrosis___ IgA deficiency___ HIV___ AIDS___ Antibody deficiency___ Complement deficiency___

Common Variable Immunodeficiency___ Other: ________________________________________________

How many times have you had pneumonia? _________________ How many per year? ___________

How many sinus infections have you had in your life? _________ How many per year? ___________

How many ear infections have you had in your life? ____________ How many per year? ___________

How many throat infections have you had in your life? __________ How many per year? ___________

Have you ever received intravenous immunoglobin (IVIG) therapy? No___ Yes____

If “yes”, please describe: _________________________________________________________

Have you ever been evaluated for primary immunodeficiency? Yes____ No____

Have you ever been tested for HIV? Yes___ No___ If “yes”, last date and result:_______________________

Family History Are there any members of the immediate family who have asthma, hay fever, eczema, rash, food allergies, drug allergies, insect

allergies, arthritis, recurring and/or frequent infections? Please list and comment.

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

Are there any hereditary diseases or other disorders that seem to occur frequently in your family (diabetes, emphysema, heart

problems)?

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

Comments:

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________


REVIEW OF SYSTEMS / ENVIRONMENTAL HISTORY

Name:________________________________ Date of Birth:___________________

Reason for today’s visit: ______________________________________________

Do you CURRENTLY HAVE ONGOING /RECURRING PROBLEMS with any of the following:

General Nose Gastrointestinal Neurologic

no problem no problem no problem no problem

failure to thrive nasal congestion heartburn headaches

fever runny nose nausea weakness

chills post nasal drip vomiting seizures

sweats nose bleed diarrhea passing out

poor appetite itching constipation dizziness

fatigue sneezing abdominal pain

malaise bloody stool Mental Health

weight loss Throat jaundice no problem

no problem depression

Eyes hoarseness Musculoskeletal anxiety

no problem difficulty swallowing no problem hyperactivity problem

blurring sore throat back pain behavior problems

discharge oral ulcers joint pain

eye pain throat clearing joint swelling Allergic /Immunologic

itchy itching stiffness no problem

red recurring infections

vision loss Cardiovascular Skin bee sting reaction

watery no problem no problem food reaction

chest pains angioedema latex reaction

Ears palpitations dryness

no problem passing out hives

earache leg swelling itching

ear discharge shortness of breath lying down rash

ringing in ears

decreased hearing Respiratory

ears popping no problem

room spinning around cough

itching chest tightness

coughing up blood

daytime sleepiness

shortness of breath

snoring

wheezing

Housing Foundation Air Conditioning Heating

house basement none none

apartment/condo crawlspace window units wood stove

mobile/ manufactured home slab central central hot air

evaporative cooler kerosene

electric space heater

natural gas


Indoor Mold Water Damage Pests Smoke Exposure Bedroom

none none none none carpet

AC vents leaky roof roaches parents ceiling fan

bathroom plumbing problems rodents spouse/partner humidifier

window frames musty odors grandparent sleeps in own bed

walls condensation caretaker shares bed

basement water stains other

Bed Outdoor Environment Pets How Many?

crib mattress none none Dog Inside:

standard mattress cattle dogs Dog Outside:

water bed chickens cats Cat Inside:

down pillow/ comforter horses birds Cat Outside:

dust ruffle goats hamsters

stuffed toys farm gerbils

wool blanket rabbits

allergy pillow cover guinea pigs

allergy mattress cover other

pets sleeps in bed


Some Medications can interfere with allergy skin testing. In order for us to obtain the most accurate results,

please stop antihistamines used for allergy treatment 5 days prior to New Patient Appointments and prior

to Skin Testing. If you have a question about whether it is safe for you to stop your antihistamine, please contact

your prescribing physician.

COMMON MEDICATIONS CONTAINING ANTIHISTAMINES INCLUDE:

Sedating Allergy Medications (All Forms)

Advil Allergy Carbinoxamine Extendryl

Alahist Chlorpheniramine Ketotifen

AlleRX Clor-Trimeton Palgic

Allergy Relief Medication Diphenhydramine (Benadryl) Polyhistine

Brompheniramine (Bromfed) Doxylamine Tylenol Allergy

Clor-Trimeton

Non-Sedating Allergy Medications (All Forms)

Cetirizine (Zyrtec, Wal-Zyr) Fexofenadine (Allegra) Loratadine (Claritin, Alavert)

Desloratidine (Clarinex) - None x 7 days

Levocetirizine (Xyzal) - None x 7 days

Nasal Sprays

Azelastine (Astelin, Astepro) Dymista Olopatadine (Patanase)

Cough/Cold /Sinus Remedies

Actifed Dimetane Semprex-D

Advil Cold/Sinus Dimetapp Sinutab

Aleve Cold Drixoral Sudafed Cold + Allergy

Alka Seltzer Plus/Cold Norel SR/MD Tanafed

Allerest Nyquil Theraflu (All forms)

BC Cold Powder Pediacare Time Hist

Benylin Cough Percogesic Triaminic (All forms)

Comtrex Phenyltoloxamine Tussionex

Contac Robitussin (many forms) Tylenol Cold+Sinus

Coricidin Rondec Vicks 44 M

Co-Tylenol Rynatan/R-Tannate Zicam

Sleep Aids

Advil PM Doxylamine Nytol

Alertec (Modafinil) Excedrin PM Sominex

Hydroxyzine (Atarax/Vistaril) Night Time Sleep Aid Tylenol PM/Tylenol Sleep

Doxepin (Sinequan)

Anti-Nausea/Vertigo Medications

Chlorpromazine Prochlorperazine (Compazine)

Dimenhydrinate (Dramamine) Promethazine (Phenergan)

Meclizine (Antivert)

Stomach Acid Medications

Cimetidine (Tagamet) Famotidine (Pepcid, Mylanta AR) Ranitidine (Zantac)

Itch Relief Medications

Cyproheptadine (Periactin) Doxepin (Sinequan) Hydroxyzine (Atarax/Vistaril)

Diphenhydramine (Benadryl)

Others

Cyclobenzaprine (Flexeril)


Do not use oil, cream or lotion on the back or arms for 24 hours prior to skin testing.

Please call your local Allergy Partners office with any questions about these lists.

Please continue taking all of the following medications as prescribed:

Antibiotics

Antidepressants

Asthma Medications- All

Blood Pressure Medications

Decongestants

Heart Medications

Inhalers

Nasal Sprays- Except Astelin/Astepro/Patanase

Steroids

Thyroid Medications

Do not stop these medications without the approval of your physician.


FINANCIAL POLICY

Our commitment is to provide the very best medical care to our patients while recognizing the need to limit services to only those that

are necessary for each patient. To meet this commitment, we recognize the need for a definite understanding and agreement

concerning our patient’s healthcare and the financial arrangements for that medical care. Your clear understanding of our financial

policies is important to our professional relationship. Please contact our billing office regarding any questions about our fees, financial

policies or your insurance coverage and your financial responsibilities

Professional Fees: Our fees for medical services are comparable to other similarly trained physicians in the community and reflect

the complexity of your specific needs, the physician time dedicated to your care, the specialized nature of the doctor’s education and

training and support costs associated with providing and coordinating your care. We will be happy to provide you with detailed fee

information at any time.

Patient Payments: Co-pays, deductibles, services not covered by your insurance plan or outstanding balances are due at the time of

your appointment. Payments may be made with cash, check or credit card. Returned checks will be subject to the fee allowed by state

regulations. Please let us know if you are having a particular financial problem and we will try our best to be understanding. Please

feel free to discuss mutually acceptable payment arrangements with our in house Financial Coordinator or our Central Billing Office.

Insurance Payments: We participate and accept assignment of payment with most major insurance plans in the area. Even though

we may submit insurance claims for you, your insurance coverage is a contract between you and your insurer and you are still

responsible for payments and services regardless of the amount your insurance pays. If your insurance company requires an

authorization or referral, it is the patient’s responsibility to obtain this for the initial visit and for continuation of care.

Additional Fees:

Missed Appointments: Please understand that when you reserve an appointment with one of our physicians, we are making a

commitment to your medical care and this prevents another patient from receiving care at that time. To assist all of our patients with

appropriate access to our physicians we may charge a fee for any office visit appointment cancelled with less than 24 hours’ notice.

Please note this fee is not covered by your insurance company.

Medical Supplies: Please note that certain medical supplies given to you at your visit require an advanced payment from you at check

out. We will submit any charges for medical supplies to your insurance company, and we will reimburse you the payment difference

made by your insurance company.

Medical Forms: The completion of disability forms, attending physician statements and other supplemental insurance forms all

require physician and staff time to complete. Accordingly, a fee may be charged to complete most of these forms. Non-standard forms

may be higher.

Nurse Visit: Please note that if a patient comes in without an appointment to speak to a nurse, depending on the time and complexity

of the visit, there may be a charge for the visit.

__________________________________________________ _________________________________

Signature of Responsible Person Date


NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND

HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

We understand the importance of privacy and are committed to maintaining the confidentiality of your medical information.

We make a record of the medical care we provide and may receive such records from others. We use these records to

provide or enable other health care providers to provide quality medical care, to obtain payment for services provided to you

as allowed by your health plan and to enable us to meet our professional and legal obligations to operate this medical

practice properly. We are required by law to maintain the privacy of protected health information, to provide individuals

with notice of our legal duties and privacy practices with respect to protected health information, and to notify affected

individuals following a breach of unsecured protected health information. This notice describes how we may use and disclose

your medical information. It also describes your rights and our legal obligations with respect to your medical information.

If you have any questions about this Notice, please contact our Privacy Officer listed above.

This medical practice collects health information about you and stores it in a chart and in an electronic health record/personal

health record. This is your medical record. The medical record is the property of this medical practice, but the information in

the medical record belongs to you. The law permits us to use or disclose your health information for the following purposes:

1. Treatment. We use medical information about you to provide your medical care. We disclose medical information to our

employees and others who are involved in providing the care you need. For example, we may share your medical information

with other physicians or other health care providers who will provide services that we do not provide. Or we may share this

information with a pharmacist who needs it to dispense a prescription to you, or a laboratory that performs a test. We may also

disclose medical information to members of your family or others who can help you when you are sick or injured, or after you

die.

2. Payment. We use and disclose medical information about you to obtain payment for the services we provide. For example, we

give your health plan the information it requires before it will pay us. We may also disclose information to other health care

providers to assist them in obtaining payment for services they have provided to you.

3. Health Care Operations. We may use and disclose medical information about you to operate this medical practice. For example,

we may use and disclose this information to review and improve the quality of care we provide, or the competence and

qualifications of our professional staff. Or we may use and disclose this information to get your health plan to authorize services

or referrals. We may also use and disclose this information as necessary for medical reviews, legal services and audits, including

fraud and abuse detection and compliance programs and business planning and management. We may also share your medical

information with our "business associates," such as our billing service, that perform administrative services for us. We have a

written contract with each of these business associates that contains terms requiring them and their subcontractors to protect the

confidentiality and security of your protected health information. We may also share your information with other health care

providers, health care clearinghouses or health plans that have a relationship with you, when they request this information to help

them with their quality assessment and improvement activities, their patient-safety activities, their population-based efforts to

improve health or reduce health care costs, their protocol development, case management or care-coordination activities, their

review of competence, qualifications and performance of health care professionals, their training programs, their accreditation,

certification or licensing activities, or their health care fraud and abuse detection and compliance efforts.

4. Appointment Reminders. We may use and disclose medical information to contact and remind you about appointments. If you

are not home, we may leave this information on your answering machine or in a message left with the person answering the

phone.

5. Sign In Sheet. We may use and disclose medical information about you by having you sign in when you arrive at our office. We

may also call out your name when we are ready to see you.

6. Notification and Communication with Family. We may disclose your health information to notify or assist in notifying a family

member, your personal representative or another person responsible for your care about your location, your general condition or,

unless you had instructed us otherwise, in the event of your death. In the event of a disaster, we may disclose information to a

relief organization so that they may coordinate these notification efforts. We may also disclose information to someone who is

involved with your care or helps pay for your care. If you are able and available to agree or object, we will give you the

opportunity to object prior to making these disclosures, although we may disclose this information in a disaster even over your


objection if we believe it is necessary to respond to the emergency circumstances. If you are unable or unavailable to agree or

object, our health professionals will use their best judgment in communication with your family and others.

7. Marketing. Provided we do not receive any payment for making these communications, we may contact you to give you

information about products or services related to your treatment, case management or care coordination, or to direct or

recommend other treatments, therapies, health care providers or settings of care that may be of interest to you. We may similarly

describe products or services provided by this practice and tell you which health plans this practice participates in. We may also

encourage you to maintain a healthy lifestyle and get recommended tests, participate in a disease management program, provide

you with small gifts, tell you about government sponsored health programs or encourage you to purchase a product or service

when we see you, for which we may be paid. Finally, we may receive compensation which covers our cost of reminding you to

take and refill your medication, or otherwise communicate about a drug or biologic that is currently prescribed for you. We will

not otherwise use or disclose your medical information for marketing purposes or accept any payment for other marketing

communications without your prior written authorization. The authorization will disclose whether we receive any compensation

for any marketing activity you authorize, and we will stop any future marketing activity to the extent you revoke that

authorization.

8. Sale of Health Information. We will not sell your health information without your prior written authorization. The authorization

will disclose that we will receive compensation for your health information if you authorize us to sell it, and we will stop any

future sales of your information to the extent that you revoke that authorization.

9. Required by Law. As required by law, we will use and disclose your health information, but we will limit our use or disclosure

to the relevant requirements of the law. When the law requires us to report abuse, neglect or domestic violence, or respond to

judicial or administrative proceedings, or to law enforcement officials, we will further comply with the requirement set forth

below concerning those activities.

10. Public Health. We may, and are sometimes required by law, to disclose your health information to public health authorities for

purposes related to: preventing or controlling disease, injury or disability; reporting child, elder or dependent adult abuse or

neglect; reporting domestic violence; reporting to the Food and Drug Administration problems with products and reactions to

medications; and reporting disease or infection exposure. When we report suspected elder or dependent adult abuse or domestic

violence, we will inform you or your personal representative promptly unless in our best professional judgment, we believe the

notification would place you at risk of serious harm or would require informing a personal representative we believe is

responsible for the abuse or harm.

11. Health Oversight Activities. We may, and are sometimes required by law, to disclose your health information to health oversight

agencies during the course of audits, investigations, inspections, licensure and other proceedings, subject to the limitations

imposed by law.

12. Judicial and Administrative Proceedings. We may, and are sometimes required by law, to disclose your health information in the

course of any administrative or judicial proceeding to the extent expressly authorized by a court or administrative order. We

may also disclose information about you in response to a subpoena, discovery request or other lawful process if reasonable

efforts have been made to notify you of the request and you have not objected, or if your objections have been resolved by a

court or administrative order.

13. Law Enforcement. We may, and are sometimes required by law, to disclose your health information to a law enforcement

official for purposes such as identifying or locating a suspect, fugitive, material witness or missing person, complying with a

court order, warrant, grand jury subpoena and other law enforcement purposes.

14. Coroners. We may, and are often required by law, to disclose your health information to coroners in connection with their

investigations of deaths.

15. Organ or Tissue Donation. We may disclose your health information to organizations involved in procuring, banking or

transplanting organs and tissues.

16. Public Safety. We may, and are sometimes required by law, to disclose your health information to appropriate persons in order

to prevent or lessen a serious and imminent threat to the health or safety of a particular person or the general public.

17. Proof of Immunization. We will disclose proof of immunization to a school that is required to have it before admitting a student

where you have agreed to the disclosure on behalf of yourself or your dependent.


18. Specialized Government Functions. We may disclose your health information for military or national security purposes or to

correctional institutions or law enforcement officers that have you in their lawful custody.

19. Workers’ Compensation. We may disclose your health information as necessary to comply with workers’ compensation laws.

For example, to the extent your care is covered by workers' compensation, we will make periodic reports to your employer about

your condition. We are also required by law to report cases of occupational injury or occupational illness to the employer or

workers' compensation insurer.

20. Change of Ownership. In the event that this medical practice is sold or merged with another organization, your health

information/record will become the property of the new owner, although you will maintain the right to request that copies of

your health information be transferred to another physician or medical group.

21. Breach Notification. In the case of a breach of unsecured protected health information, we will notify you as required by law. If

you have provided us with a current e-mail address, we may use e-mail to communicate information related to the breach. In

some circumstances our business associate may provide the notification. We may also provide notification by other methods as

appropriate.

B. When This Medical Practice May Not Use or Disclose Your Health Information

Except as described in this Notice of Privacy Practices, this medical practice will, consistent with its legal obligations, not use

or disclose health information which identifies you without your written authorization. If you do authorize this medical

practice to use or disclose your health information for another purpose, you may revoke your authorization in writing at any

time.

C. Your Health Information Rights

1. Right to Request Special Privacy Protections. You have the right to request restrictions on certain uses and disclosures of your

health information by a written request specifying what information you want to limit, and what limitations on our use or

disclosure of that information you wish to have imposed. If you tell us not to disclose information to your commercial health

plan concerning health care items or services for which you paid for in full out-of-pocket, we will abide by your request, unless

we must disclose the information for treatment or legal reasons. We reserve the right to accept or reject any other request, and

will notify you of our decision.

2. Right to Request Confidential Communications. You have the right to request that you receive your health information in a

specific way or at a specific location. For example, you may ask that we send information to a particular e-mail account or to

your work address. We will comply with all reasonable requests submitted in writing which specify how or where you wish to

receive these communications.

3. Right to Inspect and Copy. You have the right to inspect and copy your health information, with limited exceptions. To access

your medical information, you must submit a written request detailing what information you want access to, whether you want to

inspect it or get a copy of it, and if you want a copy, your preferred form and format. We will provide copies in your requested

form and format if it is readily producible, or we will provide you with an alternative format you find acceptable, or if we can’t

agree and we maintain the record in an electronic format, your choice of a readable electronic or hardcopy format. We will also

send a copy to any other person you designate in writing. We will charge a reasonable fee which covers our costs for labor,

supplies, postage, and if requested and agreed to in advance, the cost of preparing an explanation or summary. We may deny

your request under limited circumstances. If we deny your request to access your child's records or the records of an

incapacitated adult you are representing because we believe allowing access would be reasonably likely to cause substantial

harm to the patient, you will have a right to appeal our decision. If we deny your request to access your psychotherapy notes,

you will have the right to have them transferred to another mental health professional.

4. Right to Amend or Supplement. You have a right to request that we amend your health information that you believe is incorrect

or incomplete. You must make a request to amend in writing, and include the reasons you believe the information is inaccurate

or incomplete. We are not required to change your health information, and will provide you with information about this medical

practice's denial and how you can disagree with the denial. We may deny your request if we do not have the information, if we

did not create the information (unless the person or entity that created the information is no longer available to make the

amendment), if you would not be permitted to inspect or copy the information at issue, or if the information is accurate and

complete as is. If we deny your request, you may submit a written statement of your disagreement with that decision, and we

may, in turn, prepare a written rebuttal. All information related to any request to amend will be maintained and disclosed in

conjunction with any subsequent disclosure of the disputed information.


5. Right to an Accounting of Disclosures. You have a right to receive an accounting of disclosures of your health information made

by this medical practice, except that this medical practice does not have to account for the disclosures provided to you or

pursuant to your written authorization, or as described in paragraphs 1 (treatment), 2 (payment), 3 (health care operations), 6

(notification and communication with family) and 18 (specialized government functions) of Section A of this Notice of Privacy

Practices or disclosures for purposes of research or public health which exclude direct patient identifiers, or which are incident to

a use or disclosure otherwise permitted or authorized by law, or the disclosures to a health oversight agency or law enforcement

official to the extent this medical practice has received notice from that agency or official that providing this accounting would

be reasonably likely to impede their activities.

6. Right to a Paper or Electronic Copy of this Notice. You have a right to notice of our legal duties and privacy practices with

respect to your health information, including a right to a paper copy of this Notice of Privacy Practices, even if you have

previously requested its receipt by e-mail.

If you would like to have a more detailed explanation of these rights or if you would like to exercise one or more of these

rights, contact our Privacy Officer listed at the top of this Notice of Privacy Practices.

D. Changes to this Notice of Privacy Practices

We reserve the right to amend this Notice of Privacy Practices at any time in the future. Until such amendment is made, we

are required by law to comply with the terms of this Notice currently in effect. After an amendment is made, the revised

Notice of Privacy Protections will apply to all protected health information that we maintain, regardless of when it was

created or received. We will keep a copy of the current notice posted in our reception area, and a copy will be available at

each appointment. We will also post the current notice on our website.

E. Complaints

Complaints about this Notice of Privacy Practices or how this medical practice handles your health information should be

directed to our Privacy Officer listed at the top of this Notice of Privacy Practices.

If you are not satisfied with the manner in which this office handles a complaint, you may submit a formal complaint to the U.S.

Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W.,

Washington, D.C. 20201, calling 1-877-696-6775, or visiting http://www.hhs.gov/ocr/privacy/hipaa/complaints/.

You will not be penalized in any way for filing a complaint.

Privacy Officer: Denise C. Yarborough, Esquire

Allergy Partners, PA

1978 Hendersonville Road

Asheville, NC 28803

(T) (828) 277-1300

(F) (828) 277-2499

Email: [email protected]

This Notice is effective September 23, 2013; reviewed March 27, 2017.

http://www.hhs.gov/ocr/privacy/hipaa/complaints/

mailto:[email protected]


ACKNOWLEDGEMENT

I, ____________________________ (patient) acknowledge that I have received a copy of

Allergy Partners, P.A. d/b/a _________________________’s Notice of Privacy Practices.

Date: __________________ __________________________________

Patient/Guardian Signature

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