baptist medical center south • 14546 old st. augustine rd ...€¦ · baptist medical center...

Dear New Patient: Welcome to the Allergy and Asthma Care clinic. To get the best results from your visit we request that you bring all of your medications, spacer, (AeroChamber), peak flow meter and any pertinent medical records (including any previous allergy testing, vaccine formulation, x-rays, and breathing tests) with you. Additionally, please take some time to complete our new patient questionnaire which is enclosed. If you are coming for evaluation of allergic rhinitis (hay fever) and or asthma, and you would like to be skin tested on your first visit, then we request that you do NOT take any antihistamine medication for 4-5 days prior to your visit. This is to allow us to perform allergy testing, if it is necessary. If skin testing is performed, your visit will be about 90 minutes, so please plan accordingly. If you are coming for evaluation of a stinging insect reaction or drug reaction, your initial visit will not involve skin testing however you will return within a few weeks for testing and we request that you do NOT take any antihistamines 4-5 days prior to that follow up visit. If you are coming for evaluation of anaphylaxis, swelling, hives or angioedema of unknown cause or immune problems (frequent infections), please do not change any of your current medications. We look forward to your visit! Enclosures: List of medications to avoid prior to skin testing New patient questionnaire

Baptist Medical Center South • 14546 Old St. Augustine Rd., Suite 101 • Jacksonville, FL 32258

Orange Park Office • 2035 Professional Center Drive, Suite A • Orange Park, FL 32073 Phone (904) 298-1800 • Fax (904) 298-1802


Orange Park Office • 2035 Professional Center Drive, Suite A • Orange Park, FL 32073

Phone (904) 298-1800 • Fax (904) 298-1802

MEDICATIONS TO AVOID PRIOR TO ALLERGY TESTING

(MUST BE OFF ANTIHISTAMINES FOR 4-5 DAYS PRIOR TO ALLERGY TESTING!!)

Common antihistamines (Allergy medications-including Eye Drops and Nasal Sprays)

Alavert (loratadine) Dimetane-Dimetapp

Allegra (fexofenadine) Dymista

AlleRx Pataday Eye Drops

Astelin Nasal Spray Patanase Nasal Spray

Astepro Nasal Spray Phenergan (often used for nausea) (promethazine)

Atarax(hydroxyzine) Tavist (clemastine)

Benadryl (diphenhydramine) Tussionex (hydrocodone and chlorpheniramine)

Brompheniramine Tylenol Cold and Sinus (acetaminophen and diphenhydramine)

Chlor-Trimeton (chlorpheniramine) Vistaril (hydroxyzine)

Claritin (loratadine) Xyzal

Clarinex (desloratadine) Zyrtec (cetirizine)

HOLD ANY OTHER OVER THE COUNTER ALLERGY, COLD AND SINUS MEDICATION

AND ANY ALLERGY EYE DROPS

IN ADDITION DO NOT TAKE 24-48 HOURS PRIOR TO ALLERGY TESTING:

Zantac (ranitidine)

Tagamet (cimetidine)

***PLEASE DO NOT PUT LOTIONS OR PERFUMES ON BACK OR ARMS***

______________________________________________________________________________________

***YOU MAY CONTINUE THE FOLLOWING***

Nasal Sprays Inhaled medications Other

Flonase Advair Flovent Prednisone

Nasacort AQ Albuterol Pulmicort Singulair (hold 24 hrs before)

Nasonex Alvesco Serevent Accolate (hold 24 hrs before)

Nasacort Atrovent Symbicort Decongestants

Nasal crom Combivent Qvar Sudafed (not allergy formulation)

Rhinocort AQ Dulera

Veramyst

Zetonna

If on a beta-blocker (type of heart medication), schedule an early morning appointment with Dr. Watkins, and do not take

your beta-blocker on the morning of your clinic visit. Please, bring the pill with you as you will be expected to take it to

get back on your medication schedule once skin testing has been completed. Be sure to notify Dr. Watkins that you are

on a beta-blocker when you see her in clinic.

AS PART OF THE MEDICAL RECORD, THE FOLLOWING INFORMATION WILL BE RELEASED UNLESS STRICKEN: SEXUAL ABUSE INFORMATION, DRUG & ALCOHOL INFORMATION, CHILD ABUSE & NEGLECT INFORMATION, PSYCHIATRIC

INFORMATION, AIDS/HIV. I HAVE CAREFULLY READ THIS CONSENT, UNDERSTAND ITS CONTENTS AND AUTHORIZE THE RELEASE OF THE ABOVE SPECIFIED INFORMATION TO THE PERSON/FACILITY TO WHICH IT IS ADDRESSED ONLY. THE CONFIDENTIALITY OF THIS INFORMATION IS PROTECTED BY FEDERAL LAW. THE INFORMATION USED OR DISCLOSED

PURSUANT TO THIS AUTHORIZATION MAY BE SUBJECT TO REDISCLOSURE BY THE RECIPENT AND NO LONGER PROTECTED BY FEDERAL LAW. I MAY CANCEL THIS AUTHORIZATION IN WRITING AT ANY TIME.

THIS AUTHORIZATION WILL EXPIRE ONE YEAR FROM FATE OF SIGNATURE.



Release Records To: Date of Release Request: Watkins Allergy & Asthma Clinic

Patient’s Name: Patient’s Date of Birth:

Description:

Patient’s Signature:

This message is confidential, intended only for the named recipient(s) and may contain information that is privileged or exempt from disclosure under applicable law. If you are not the intended recipient(s), you are notified that the dissemination, distribution or copying of this message is strictly prohibited. If you receive this message an error, or are not the named recipient(s), please notify the sender at the fax address or telephone number and discard this fax. Thank you.

To:

Financial Policy Dear Patient/ Patient Guardian, Thank you for choosing Watkins Allergy & Asthma Clinic for your health care needs. Our primary concern is centered on you, our patient, and that you receive the proper care needed to restore your health. Our financial policy is a necessary part of assuring the financial resources required to maintain the vital health care facility for our patients and our community. Therefore, we ask that you please read the following and sign prior to having your appointment. Payments are due at the time services are rendered, unless prior arrangements have been made with our billing department. Co-payments and deductibles are due at the time services are rendered. We gladly accept cash, checks and for your convenience, we accept all major credit cards. All returned checks are subject to a $25.00 returned check fee. Please ensure that we have a copy of your most current insurance card on file, and that if any changes occur with your insurance that we are notified immediately. This will ensure that we have acquired the proper authorization required by your health care plan, to perform your procedure. It is important that you understand we view your insurance as a contract between you, your employer and the insurance company, therefore, we cannot become involved in disputes between you and your insurance company regarding deductibles, co-payments, covered charges, etc. Our services are rendered to you, not your insurance company. We participate in many different health plans and programs and currently accept assignment with Medicare, and participate with most managed care plans. Also, not all services are a covered benefit. Please be aware of your benefit package with your insurance company. Any charges not paid by your insurance company are solely your responsibility. We file secondary insurances as a courtesy. If your secondary insurance fails to remit payment within 60 days, we require you to pay the remaining balance. Patient statements are mailed monthly. Please pay promptly upon receiving statement. All outstanding balances older than 90 days will be subject to review and forwarded to our collection department where an additional $25.00 collection fee will be added to the account balance and forwarded to the Credit Bureau. We understand that temporary financial problems may affect timely payment. We encourage you to contact our billing department to make arrangements. Again, thank you for choosing us for your health care needs, and we appreciate the opportunity to serve you. Patient/ Parent or Guardian’s Signature: ____________________________________________ Date: ___________ Patient/ Parent or Guardian’s Name (Please Print):_____________________________________ By my signature, I indicate that I have read this policy and agree to its provision.



— Notice of Privacy Policy —THlS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSEDAND HOW YOU CAN GET ACCESS TO THlS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Introduction

At Watkins Allergy and Asthma Clinic, we are committed to treatingand using protected health information about you responsibly.This notice of health information practices describes the personalinformation we collect and how and when we use or disclosethat information. It also describes your rights as they relate toyour protected health information. This Notice is effective April14, 2003, and applies to all protected health information as definedby federal regulations.

Understanding Your Health Record/Information

Each time you visit Watkins Allergy and Asthma Clinic, a recordof your visit is made. Typically, this record contains your symptoms,examination notes, test results, diagnoses, treatment, and a planfor future care or treatment. This information, often referred toas your health or medical record, serves as a:

• Basis for planning our care and treatment,

• Means of communication among the many healthprofessionals who contribute to your care,

• Legal document describing the care you received,

• Means by which you or a third-party payer can verify thatservices billed were actually provided,

• Tool in educating health professionals,

• Source of data for medical research,

• Source of data for our planning and marketing, and

• Tool with which we can access and improve the care we tenderand the outcomes we achieve.

Understanding what is in your record and how your healthinformation is used helps you to ensure its accuracy; betterunderstand who, what, when, where, and why others may accessyour health information; and make more informed decisions whenauthorizing disclosure to others.

Your Health Information Rights

Although your health record is the physical property of WatkinsAllergy and Asthma Clinic, the information belongs to you.You have the right to:

• Obtain a paper copy of this Notice of PrivacyPractices upon request,

• Inspect and copy your health record as provided for in45 CFR 164.524,

• Amend your health record as provided in 45 CFR 164.524,

• Obtain an accounting of disclosures of your health informationas provided in 45 CFR 164.538,

• Request communications of your health information byalternative means or at alternative locations,

• Request a restriction on certain uses and disclosures of yourinformation as provided by 45 CFR 164.522, and

• Revoke your authorization to use or disclose health informationexcept to the extent that action has already been taken.

Our Responsibilities

Watkins Allergy and Asthma Clinic is required to:

• Maintain the privacy of your health information,

• Provide you with this notice as to our legal duties and privacypractices with respect to information we collect and maintainabout you,

• Abide by the terms of this notice,

• Notify you if we are unable to agree to a requested restriction,and

• Accommodate reasonable requests you may have tocommunicate health information by alternative means or atalternative locations.

Watkins Allergy and Asthma Clinic

Watkins Allergy and Asthma ClinicIn Association With Borland-Groover Clinic

Acknowledgement of Receipt of Privacy PolicyWe are required by law to provide you with our Notice of Privacy Practices.

To ensure that our records are accurate, please sign this form and return it to our receptionistto acknowledge that you have been provided with a copy of our notice.

I hereby authorize Watkins Allergy and Asthma Clinic (In Association With Borland-Groover Clinic) to share and/or discuss my medical information with the following individuals:

I acknowledge receipt of Watkins Allergy and Asthma Clinic’s Notice of Privacy Practices.

_________________________________________________________ __________________________Patient/Parent or Guardian's Signature Date

_________________________________________________________Patient’s Name (please print)

1. 2.

In Association With Borland-Groover Clinic

We reserve the right to change our practices and to make newprovisions effective for all protected health information wemaintain. Should our information practice change, we will mail arevised notice to the address you’ve supplied us, or, if you agree,we will mail the revised notice to you.

We will not use or disclose your health information without yourauthorization, except as described in this notice. We will alsodiscontinue to use or disclose your health information after wehave received a written revocation of the authorization accordingto the procedures included in the authorization.

For More Information or to Report a Problem

If you have questions and would like additional information, youmay contact our Privacy Officer, Vicki King at (904) 398-3262.

If you believe your privacy rights have been violated, you can filea complaint with the Privacy Officer, or with the Office for CivilRights. There will be no retaliation for filing a complaint witheither the Privacy Officer or the Office for Civil Rights. The addressfor the OCR is listed below:

Office for Civil RightsU.S. Department of Health and Human Services200 Independence Avenue, S.W.Room 509F, HHH BuildingWashington, D.C. 20201

Examples of Disclosures for Treatment, Payment andHealth Operations (TPO)

We will use your health information for treatment.

For example: Information obtained by a nurse, physician, or othermember of your health care team will be recorded and used todetermine the course of treatment that should work best for you.Your physician will document in your record his or herexpectations of the members of your health care team. Membersof your health care team will then record the actions they tookand their observations. In that way, the physician will know howyou are responding to treatment.

We will also provide your physician or a subsequent health careprovider with copies of various reports that should assist him orher in treating you once you’re discharged from the hospital.

We will use your health information for payment.

For example: A bill may be sent to you or a third-party payer. Theinformation on or accompanying the bill may include informationthat identifies you, as well as your diagnosis, procedures, andsupplies used.

We will use your health information for normal health operations.

For example: Members of the medical staff, the risk or qualityimprovement manager, or members of the quality improvementteam may use information in your health record to assess the careand outcomes in your case and others like it. This informationwill then be used in an effort to continually improve the qualityand effectiveness of the healthcare and service we provide.

Business associates: There are some services provided in ourpractice through contacts with business associates. Examplesinclude physician services in the emergency department,radiology, and certain laboratory tests. When these services arecontracted, we may disclose your health information to ourbusiness associate so that they can perform the job we’ve askedthem to do and bill you or your third-party payer for services

rendered. To protect your health information, we require ourbusiness associate to safeguard your information.

Notification: We may use or disclose information to notify or assistin notifying a family member, personal representative, or anotherperson designated for your care.

Communication from offices: We may call your home or otherdesignated location and leave a message on voicemail or in personin reference to any items that assist the practice in carrying outTPO such as appointment reminders, insurance items, and anyother call pertaining to your medical care. We may mail to yourhome or other designated location any items that assist the practicein carrying out TPO such as appointment reminder cards andpatient statements. We may e-mail to your home or otherdesignated location any items that assist the practice in carryingout TPO such as appointment reminder cards and patientstatements.

Communication with family: Health professionals, using theirbest judgment, may disclose to a family member, other relative,close personal friend or any other you identify, health informationrelevant to that person’s involvement in your care or payment ofyour care.

Open treatment areas : Patient care is sometimes provided in anopen treatment area. While special care is taken to maintainpatient privacy, some patient information may be overheard byothers while receiving treatment. Should you be uncomfortablewith this, please bring this to the attention of our Privacy Officer.

Research: We may disclose information to researchers when theirresearch has been approved by an institutional review board thathas received the research proposal and established protocols toensure the privacy of your health information.

Marketing: We may contact you to provide appointmentreminders, information about treatment alternatives, or otherhealth-related benefits and services that may be of interest to you.

Fundraising: We may contact you as part of a fundraising effort.

Food and Drug Administration (FDA): We may disclose to theFDA health information relative to adverse events with respectto food, supplements, or product and produce defects. We mayalso disclose post-marketing surveillance information to enableproduct recalls, repair, or replacement.

Workers compensation: We may disclose health information tothe extent authorized by and to the extent necessary to complywith laws relating to workers compensation or other programsestablished by law.

Public health: As required by law, we may disclose your healthinformation to public health or legal authorities charged withpreventing or controlling disease, injury, or disability.

Law enforcement: We may disclose health information for lawenforcement purposes as required by law or in response to a validsubpoena. Federal law makes provision for your healthinformation to be released to an appropriate health oversightagency, public health authority, or attorney, provided that aworkforce member or business associate believes in good faiththat we have engaged in unlawful conduct or have otherwiseviolated professional or clinical standards and are potentiallyendangering one or more patients, workers, or the public.

IF YOU HAVE QUESTIONS REGARDINGTHIS POLICY, PLEASE CONTACT THE

PRIVACY OFFICER

Watkins Allergy and Asthma ClinicPATIENT GENERATED MEDICAL HISTORY

Name: Date of Birth: Date of Service: Reason for Visit: Primary Care Provider: Referring Provider: Send Records to: Pharmacy (Name/Address): Pharmacy Phone Number:

UNDER 15 YEARS OF AGE ONLY(Circle all that apply to you) Yes/NoImmunizations up to date? Y/NFull Term? Y/NBottle/Breast fed CircleFeeding Problems? Y/NHas persistent infections? Y/NGrowth/development normal? Y/N

DRUG ALLERGY REACTION

ADULTS: Have you ever had the following?(Circle all that apply to you) Yes/NoTetanus shot Y/NPneuomonia vaccine Y/NFlu shot Y/NAnything else we should know:

YOUR SOCIAL HISTORY:

Occupation Working / Retired

Tobacco? Y / N /Former

❑ want to quit / cutback?

❑ passive / second hand exposure

Alcohol? Y / N /Former

Marital Status: M S D W L

Children: # of sons: # of daughters:

Education (level):

Pets: Y / N Birds/Dogs/Rodents/Cats/Reptiles

Mother: Alive? Y/N If no, cause

Father: Alive ? Y/N If no, cause

Sister: Alive ? Y/N If no, cause

Brother: Alive? Y/N If no, cause

Other Diseases That Run In The Family:

YOUR FAMILY HISTORY:

Allergies

Asthma

Immune Deficiency

Cystic Fibrosis

Multiple Miscarriages

P/M

P/M

P/M

P/M

P/M

RELATIONSHIP AGETYPEPaternal/Maternal

HOBBIES:

Directions: Please answer any of the following you have personally had during your life: Directions: Please circle any of the following that exists in your family.

Women OnlyLAST MENSTRUAL PERIOD Could you be pregnant? Y / N

YOUR PAST MEDICAL HISTORY:(Circle all that apply to you) Yes/NoAsthma Y / N COPD Y / N Emphysema Y / NEczema Y / N Coronary Artery Disease Y / N Diabetes Mellitus: Y / N Type 1 Type 2High Blood Pressure Y / N HIV Y / NHepatitis Y / N Do you have a personal history of cancer?(Circle the following that apply)Breast Liver PancreasColon Lung ProstateEsophagus Ovary StomachUterus Other________________

Watkins Allergy and Asthma ClinicALLERGY REVIEW OF SYSTEMS

Directions: Have you had any of the following in the last six months?

Chest pain

Swelling in extremities

Palpitations

Abdominal pain

Blood in stool

Change in bowel habits

Constipation

Diarrhea

Heartburn

Loss of appetite

Nausea

Vomiting

Trouble swallowing

Vomiting blood

Black stool

Reflux

Hives

Itching

Rash

Eczema

Dizziness

Numbness

Headache

Tremors

Sensation of Room spinning

Anxiety

Depression

Increased stress

Back pain

Joint pain

Joint swelling

Easy bleeding

Easy bruising

Swollen lymph glands

Contact allergy

Food allergies

Seasonal allergies

Animals at home

Animals in workplace

Asthma

Chemicals in workplace

Immunosuppression

Insect allergy

No Yes No Yes No Yes No Yes

No Yes

No Yes

No Yes

No Yes

No Yes

No Yes

No Yes

No Yes

Name Date of Birth: Date of Service:

ChillsFatigueFeverWeight loss

Ear painEye painHearing lossSinus pressureBurning EyesDouble visionDry eyesEye rednessItchy eyesWatery eyesEar infectionsImpaired sense of smellNasal congestionRunny noseSinus infectionsSneezingHoarsenessPost nasal drainageDark circles under eyesItchy noseItchy throat

❑ ❑❑ ❑❑ ❑❑ ❑

No YesFrequent coughKnown TB exposureShortness of breathWheezingPain with breathing

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Painful urination

Blood in urine

Urinary frequency

Urinary incontinence

Urinary retention

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Cold intolerance

Heat intolerance

Excessive thirst

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Watkins Allergy and Asthma ClinicASTHMA SYMPTOMS

ASTHMA SYMPTOMS WITH:

Allergies Y/N

Daytime activities Y/N

Exercise Y/N

Life support Y/N

Nighttime Y/N

Perfumes, scents Y/N

Seasonal Y/N

Chronic Steroids Y/N

SYMPTOMS BETTER WITH:

Inhalers Y/N

Fresh Air Y/N

Nose sprays Y/N

Oral steroids Y/N

Over the counter meds Y/N

Rest Y/N

WHICH ONE:

ASTHMA SYMPTOMS:

Cough Y/N

Shortness of breath Y/N

Hoarseness Y/N

Nighttime symptoms Y/N

Thrush Y/N

AsthmaSymptoms

Interferencewith activity

Nighttimeawakenings

Albuterol use

2 or less days a week

none

2 or less times a month

2 or less days a week

More than2 days a weekbut not daily

minor limitation

3-4 times amonth

2 or more days a week,but not daily andnever more than

one time on any day

daily

some limitation

1 or more times a week

daily

throughout the day

extremely limited

often-up to 7 times a week

several times a dayDO YOU HAVE:

Reflux Y/N

Seasonal allergies Y/N

Side effects from asthma meds Y/N

Chronic sinus symptoms Y/N

Wheezing Y/N

ALLERGY HISTORY:

Symptoms triggered by:(Circle all that apply to you)

Aerosols, allergies, aspirin,

chemicals, cold air, dry air, dust,

exercise, flowers, food, heat,

infections, mold, mornings, pets,

pet/animal pollution, plants,

smoke, weather, other:

changes in season:

Spring / Summer / Fall / Winter

AGGRAVATED BY:

Chemicals Y/N

Animals Y/N

Chalk dust Y/N

Weather changes Y/N

Roaches Y/N

Drugs Y/N

Dust Y/N

Mold Y/N

Food Y/N

Pollen Y/N

Cold symptoms Y/N

Smoke Y/N

Directions: Please circle if the answer is yes:Directions: Please complete if you have concerns about asthma:

n/a

n/a

n/a

Severity

AsthmaSymptoms

Has required oralsteroids

(Prednisone)

Nighttimeawakenings

Albuterol use

2 or lessdays a week

0-1 times a year

2 or lesstimes a month

2 or lessdays a week

More than 2 days a week

1-3 times a week

More than 2 days a week,but not daily

throughout the day

More than 2 times a year

more than 4 times a week

several times a day

Directions: Please circle if the answer is yes:

Control

ENVIRONMENTAL HISTORY:Current home age in years: Carpeting / hardwood or tile Y / NCentral heat or air / windows open often Y / N

Name Date of Birth: Date of Service:

Watkins Allergy and Asthma Clinic

Drug Name Dosage Drug Name Why do you take the medicine?Why do you take the medicine? Dosage

MEDICATION LOG

NAME: DOB:

DIRECTIONS: Please list any over the counter or prescribed medications you currently take.

baptist medical center south • 14546 old st. augustine rd ...€¦ · baptist medical center...

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