New Patient Forms

Pediatric Patient Form

Please fill out the form below. Infant to 17.

Step 1 of 21

SUGAR LAND ALLERGY, ASTHMA & IMMUNOLOGY CENTER, P.A.

4820 Sweetwater Blvd. Sugar Land, TX 77479
281-494-4600 (Phone) 281-494-4605 (Fax)
David Amran, M.D., F.A.A.A.A.I.

**For skin testing stop antihistamines 5-7 days prior to appointment. Continue all other medications including your asthma medicines. Please do not wear perfumes or colognes to the office. (This information needs to be updated every 3 months or as needed due to any changes.) Option: Print and answer all questions and present to the front desk upon arrival for your appointment.

Patient's Information

Primary Care Physician:

Primary Care Physician Phone Number:

Pharmacy Name:

Pharmacy Number:

Referred By:

Name:(Required)

First Middle Last

Date of Birth:(Required)

Month

Day

Year

SSN:

Sex:(Required)

Male

Female

Driver's License#:(Required)

Race:

American Indian/Alaska Native

Asian

Black or African American

Hispanic

Jewish Ashkenazi

Jewish Sephardic

Middle Eastern/Arabic

Multiracial

National Hawaiian/Pacific Islander

White

Other

Address:(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number (Cell/Home):(Required)

Email:(Required)

Marital Status:

Student?

Yes

Employer:(Required)

Occupation:

Employer Address:

Street Address Address Line 2 City State ZIP / Postal Code Country

Work Phone:

Reason for Visit (Symptoms):(Required)

Emergency Contact

Name:

Relationship:

Phone Number 1:

or Phone Number 2:

INSURANCE

*If there is two active insurances, a primary and ,secondary plan need to be established and both insurances need to be aware of each other; call both plans and state you want to update Coordination of Benefits.
Primary Insurance: (HMO plans need to have a referral from your PCP before being seen in our office.)

Name of Insurance:

Phone Number:(Required)

Policy/Subscriber ID:(Required)

Group Number:(Required)

Referral Number:

Relationship to Patient:

Guarantor Name:(Required)

First Middle Last

Date of Birth:(Required)

Month

Day

Year

SSN:

Sex:

Male

Female

Driver's License#:

Address:

Street Address Address Line 2 City State ZIP / Postal Code Country

Phone Number (Cell/Home):

Email:

Employer:

Occupation:

Employer Address:

Street Address Address Line 2 City State ZIP / Postal Code Country

Work Phone:

Secondary Insurance:(HMO plans need to have a referral from your PCP before being seen in our office.)

Name of Insurance:

Phone Number:

Policy/Subscriber ID:

Group Number:

Referral Number:

Relationship to Patient:

Guarantor Name:

First Middle Last

Date of Birth:

Month

Day

Year

SSN:

Sex:

Male

Female

Driver's License#:

Address:

Street Address Address Line 2 City State ZIP / Postal Code Country

Phone Number (Cell/Home):

Email:

Employer:

Occupation:

Employer Address:

Street Address Address Line 2 City State ZIP / Postal Code Country

Work Phone:

If my insurance plan denies payment due to coverage changes, wrong benefits given by ins., member ID changes, cobra payment, current referral or I (patient/guardian) failing to provide our office with current coverage information for services rendered. I agree to be personally responsible for payment of these services.

Patient/Guardian Signature:(Required)

Date:(Required)

MM slash DD slash YYYY

NO INSURANCE (SELF PAY)

If you do not have insurance, payment is due in full at time of service.

Patient/Guardian Signature:

Date:

MM slash DD slash YYYY

Sugar Land Allergy, Asthma & Immunology Center
(PLEASE READ ALL CAREFULLY & SIGN BELOW)

FINANCIAL POLICY

We appreciate the confidence you have expressed in selecting our Physician/ Physician Assistant's as your Allergist. If you have any questions about our services, fees, or other aspects of your care please feel free to discuss them with our Front Desk/Billing Personnel.
Your clear understanding of our Financial Policy is important to our professional relationship.

Payment in full for services rendered is required at the time of service which include:
(Copays/Deductibles/Coinsurance/OOP/Non-Covered Services)

Patients without insurance or patients who are not covered by one of our contracted insurance plans.
Patients who do not provide us with current contracted insurance information.
Patients who are required to have prior referral/authorization from their insurance carrier or Primary Care Physician, who have not obtained such authorization; (in which you should contact your PCP office).
As well as any services rendered in office which is not covered by the insurance and patient chooses to continue with treatment; patient will be considered Self Pay.
- As a courtesy our front office staff will call your insurance company to verify benefits using the provider services phone number given on your insurance card.
  THIS VERIFICATION IS NOT A GUARANTEE OF PAYMENT (OUR OFFICE WILL NOT BE RESPONSIBLE FOR INCORRECT BENEFITS GIVEN TO US BY YOUR INSURANCE OR FOR CHANGES IN COVERAGE), IT IS YOUR (Patient/Guarantor/Guardian) RESPONSIBILITY TO KNOW AND UNDERSTAND YOUR OWN INSURANCE BENEFITS, COVERAGE, AND REFERRAL/AUTHORIZATIONS REQUIREMENTS.
- Our billing staff will file your claims with your Primary and Secondary insurance only (as long as your Coordination of Benefits is updated with your Primary & Secondary Plans). It is Mandatory to provide our office with all medical coverage, including insurance through your employer and/or government insurance.

ACKNOWLEDGEMENT AND AUTHORITY

I consent to treatment as necessary or desirable to the care of the patient first name below, including but not restricted to whatever drugs, medicine, conduct of laboratory, x-ray, or other studies that may be used by the physician, nurse, or qualified designate. I authorize Sugar Land Allergy to release information as required to my PCP, my insurance, or third party payor for the purpose of determining benefits. l also authorize Sugar Land Allergy to bill my insurance or third party payor and receive payment from them for services rendered. This authorization shall remain valid until such time as I revoke it in writing. A photocopy or facsimile copy of this authorization shall be deemed as valid as the original.

NOTICE OF BALANCE PAYMENT

Please know you will be made aware of any outstanding balance on your account through statements in mail. You will be required to make a payment or payment arrangements on any outstanding balance you may have accrued prior to scheduling a follow-up appointment with us. However, after 90 days of nonpayment or a total of 3 mailed statements your case will be sent to our collection agency.

Print Patient name:

Patient/Guardian Signature:(Required)

Date:(Required)

MM slash DD slash YYYY

NO SHOW POLICY

We make every effort to provide prompt medical care to all of our patients. If you are unable to keep a scheduled appointment, please let us know 24 hours in advance. A no show fee may generate a $25.00 fee per incident.
In the event that you have a special circumstance regarding your missed appointment, please contact our office. We understand that there may be issues beyond your control and want to be understanding of special circumstances.

LATE POLICY

Sugar Land Allergy, Asthma, & Immunology Center, P.A is diligently working to provide excellent medical care to every patient in a timely manner.
Please contact our office if you will be late for your appointment. There is a 15 minute grace period as long as we have been made aware, anything later we will have to reschedule to our next available appointment.

ADMINISTRATIVE PAPERWORK FEE

Sugar Land Allergy, Asthma, & Immunology Center, P.A will charge $25.00 administrative fee for any forms, paperwork that we are asked to complete or write for you. The fee is payable at the time the forms are submitted for completion. Forms requiring the fee would include, but not limited to FMLA paperwork, school forms, detailed release to work forms, medication assistance forms, etc.
*For any school forms required to be completed if the patient has not been seen in the office within 3 months the patient would need to be scheduled and be seen by one of our providers before any school forms are completed. Office visit charges would be in addition to the $25.00 administrative fee.
Please allow 7-10 business days for all forms to be completed; completed forms can be picked up from the front desk or can be faxed (if requested and not over 25 pages).

MEDICAL RECORDS

Sugar Land Allergy, Asthma, & Immunology Center, P.A will provide your records to you once you have completed the appropriate medical records request form.You can contact our office and we can mail or fax the form to you.
Fee for records, $25.00 for the first 25 pages and 50 cents for every page after.
Your request will be processed and fulfilled within 15 business days.

RETURNED CHECKS NSF

There is a $35.00 charge for any returned checks in addition to the insufficient funds amount.

Patient Name:

Patient/Guardian Signature:(Required)

Date:(Required)

MM slash DD slash YYYY

Patient Name:

MESSAGE AUTHORIZATION

Sugar Land Allergy, Asthma, and Immunology Center, P.A.

Considers patient confidentiality to be of utmost important and concern. In an effort to ensure your privacy is protected, please read and sign the following concern.

AUTHORIZATION

(Initial) I, authorize Dr. Amran/ office staff to leave a message on my home answering machine pertaining to my medical care such as appointments, results, etc. (Required)(Required)

(Initial) I, authorize Dr. Amran/ office staff to leave a message on my home answering machine pertaining to my medical care such as appointments, results, etc. (Required)

(Initial) I, authorize Dr. Amran/ office staff to leave a message on my work answering machine pertaining to my medical care such as appointments, results, etc. (Required)(Required)

(Initial) I, authorize Dr. Amran/ office staff to leave a message on my work answering machine pertaining to my medical care such as appointments, results, etc. (Required)

(Initial) I, authorize Dr. Amran/ office staff to discuss my medical care with (please list all names that apply) (Required):(Required)

(Initial) I, authorize Dr. Amran/ office staff to discuss my medical care with (please list all names that apply) (Required):

Names

I understand that this authorization will remain in effect until such time that I submit, in writing, revocation of my authorization. I understand that by giving my consent, information about my personal health care could be made available to members of my family and/or others who have access to my telephone messaging system.

Signed:(Required)

Date:(Required)

MM slash DD slash YYYY

NO AUTHORIZATION

I do not authorize any messages related to my healthcare to be left on my home answering machine.
I do not authorize any messages related to my healthcare to be left on my work answering machine.

Signed:

Date:

MM slash DD slash YYYY

AUTHORIZATION REVOKED

Message authorization revoked on (date):

Month

Day

Year

Initials of individual receiving written revocation:

ACKNOWLEDGEMENT

I, (patient), acknowledge that I have seen a copy of Sugar Land Allergy, Asthma & Immunology Center
(the practice's)
Notice Regarding Privacy of Personal Health Information.

Patient's Signature:(Required)

Date:(Required)

MM slash DD slash YYYY

Patient/Guardian Signature:(Required)

Date:(Required)

MM slash DD slash YYYY

If you would like an original copy of the Privacy Information please ask the front desk.

Parking Notice-Effective April 1, 2010
TO PREVENT TOWING OF YOUR VEHICLE!

PLEASE SIGN IN WITH OUR FRONT DESK DURING BUSINESS HOURS IF YOU ARE PARKED IN THE FRONT OR SIDE OF OUR BUILDING AND ARE PLANINGS TO WALK OVER TO ANOTHER PLACE OF BUSINESS PRIOR TO YOUR TREATMENT IN OUR OFFICE OR AFTER YOUR TREATMENT AT SUGAR LAND ALLERGY, ASTHMA & IMMUNOLOGY CENTER, P.A.
ALL UNAUTHORIZED VEHICLES PARKED IN OUR RESERVED SPACES BEFORE OR AFTER SUGAR LAND ALLERGY, ASTHMA & IMMUNOLOGY CENTER, P.A. BUSINESS HOURS. WILL BE TOWED.
OUR RESERVED PARKING IS FOR OUR PATIENTS/VISITORS THAT ARE HAVING TREATMENT IN OUR OFFICE ON THAT DAY
TOWING IS ENFORCED AT ALL TIMES

This is an acknowledgment that you have been informed and understand the above towing rules for S.L.A.

Patient Name:(Required)

Date:(Required)

MM slash DD slash YYYY

Patient/Guardian Signature:(Required)

Date:(Required)

MM slash DD slash YYYY

PEDIATRIC PATIENT QUESTIONNAIRE

PATIENT'S NAME:(Required)

BIRTHDATE:(Required)

Month

Day

Year

Parent's marital status

Married

Divorced

Separated

Single

Unknown

Other

Other (specify)

Child lives with

Both parents

Father

Mother

Other

Other (specify)

PAST MEDICAL HISTORY

Length of pregnancy

Full-term

Early

Late

# of weeks

Birth weight

Type of delivery

Vaginal, normal

Vaginal, breech

Planned C-section

Emergency C-section

Were there problems with the pregnancy? If yes, specify

Were there problems with the labor or delivery? If yes, specify

Did your child have breathing problems at birth?

Yes

If yes, specify

Was your child breast fed?

Yes

Specify # of months

Was your child formula fed?

Yes

Specify formula type

Cow's milk

Soy milk

Other

Did your child have colic?

Yes

What was your child's growth pattern?

Normal

Rapid

Slow

What was your child's development rate (sitting, crawling, walking, talking)?

Normal

Delayed

Has your child had any of the following illnesses?

Chicken pox

Yes

Has your child been vaccinated?

Yes

RSV

Yes

Has your child been vaccinated?

Yes

Ear infections

Yes

Age of Onset

Sinus infections

Yes

Age of Onset

Pneumonia

Yes

Age of Onset

Croup

Yes

Age of Onset

Other illness (specify)

Has your child been hospitalized?

Yes

If yes, how many times has your child been hospitalized?

Date

Month

Day

Year

Reason:

Date

Month

Day

Year

Reason:

Date

Month

Day

Year

Reason:

Date

Month

Day

Year

Reason:

Date

Month

Day

Year

Reason:

PAST SURGICAL HISTORY

Has your child had any surgeries?

Yes

If yes, complete the following:

Ear Tube(s): Year

Reflux surgery: Year

Tonsillectomy: Year

Appendectomy: Year

Adenoidectomy: Year

Hernia Repair: Year

Sinus Surgery: Year

Other (specify): Year

IMMUNIZATION HISTORY

Are your child's immunizations up to date?

Yes

Explain

Did your child have a flu shot this year?

Yes

ALLERGY HISTORY

Is your child allergic to food? If Yes, mark all that apply.

Milk

Egg

Soy

Wheat

Peanuts

Tree nuts (i.e. walnuts, pecans, etc.)

Shellfish

Fish

Other

Other (specify)

Is your child allergic to animals?

Yes

Unknown

Animal

Cats

Dogs

Other

Is your child allergic to medications?

Yes

Unknown

Specify

Is your child allergic to

bee

wasp

yellow jacket

hornet sting

Is your child allergic to

ant strings

mosquitoes

Does your child have

atopic dermatitis

eczema

Does your child have frequent hives or swelling?

Yes

Unknown

Does your child have nasal allergies?

Yes

Unknown

If Yes, when? (mark all that apply)

Spring

Summer

Fall

Winter

Does your child have eye symptoms from allergies?

Yes

Unknown

If Yes, when? (mark all that apply)

Spring

Summer

Fall

Winter

FAMILY MEDICAL HISTORY

Child's Father Age

Occupation

Does he have any of the following conditions?

No allergies

Allergy to animals

Asthma

Food allergy

Hay fever

Insect sting allergy

Latex allergy

Medication allergy

Eczema

Child's Mother Age

Occupation

Does he have any of the following conditions?

No allergies

Allergy to animals

Asthma

Food allergy

Hay fever

Insect sting allergy

Latex allergy

Medication allergy

Eczema

Child's Brothers/Sisters?

Sibling 1 Age

Gender

Male

Female

Does he have any of the following conditions?

No allergies

Allergy to animals

Asthma

Food allergy

Hay fever

Insect sting allergy

Latex allergy

Medication allergy

Eczema

Sibling 2 Age

Gender

Male

Female

Does he have any of the following conditions?

No allergies

Allergy to animals

Asthma

Food allergy

Hay fever

Insect sting allergy

Latex allergy

Medication allergy

Eczema

Sibling 3 Age

Gender

Male

Female

Does he have any of the following conditions?

No allergies

Allergy to animals

Asthma

Food allergy

Hay fever

Insect sting allergy

Latex allergy

Medication allergy

Eczema

Does any family member have cystic fibrosis?

Yes

Does any family member have any other type of lung disease?

Yes

Number

Specify

HOME ENVIRONMENTAL HISTORY

What type of dwelling does the child live in?

Apartment

Condo

House

Townhouse

Mobile home

Other

Other (specify)

What year was the current residence built or age in years?

How long has the child lived in the current residence?

Is there a basement?

Yes

Select all that apply

Finished

Unfinished

Dry

Damp

Flood damage

What type of heating system does the residence have?

Electric baseboard heat

Fireplace

Forced hot air(gas)

Hot water radiator or furnance

Space heater

Wood burning stove

Other

Other (specify)

What type of cooling system does the residence have?

Central air conditioning

Swamp cooler

Window(room) air conditioning

None

What type of air filtering unit does the residence have?

Central air filter

Portable air filter

None

Unknown

What type of humidifier is in the residence?

Humidifier on central system

Portable humidifier

None

Unknown

What type of window coverings are there in the residence?

Curtains

Venetian binds

Other

Other (specify)

What type of furnishings does your child's bedroom have?

Flooring:

Carpet

Hardwood

Tile

Other

Other (specify)

Pillow(s)

Feather

Foam

Polyfill

Other

Other (specify)

How old are the pillows in years?

Mattress:

Regular

Waterbed

Other

Other (specify)

How old is the mattress (years/months)?

How many stuffed animals are in the bedroom?

How many smokers live in the residence?

Child (patient)

Father

Mother

Sibling(s)

Other relatives

Other visitors

Do you have pets/animals?

Birds(s) number:

status

Indoor

Outdoor

Indoor/Outdoor

In bedroom

Cat(s) number:

status

Indoor

Outdoor

Indoor/Outdoor

In bedroom

Dog(s) number:

status

Indoor

Outdoor

Indoor/Outdoor

In bedroom

Other 1 number:

status

Indoor

Outdoor

Indoor/Outdoor

In bedroom

Other 2 number:

status

Indoor

Outdoor

Indoor/Outdoor

In bedroom

HEALTH PROBLEMS (REVIEW OF SYSTEMS)

General symptoms

Fatigue

Fever/chills

Trouble sleeping

Loss of appetite

Other

Other (specify)

Eyes

Blurred vision

Burning

Cataracts

Frequent blinking

Far-sighted

Itching

Lazy eyes

Near-sighted

Redness

Swelling

Watery eyes

Wears glasses

Other

Other (specify)

ENT

Change in sense of smell

Dry mouth

Ear pain

Enlarged lymph nodes

Hearing loss

Hoarseness/change in voice

Itchy eyes

Itchy nose

Mouth breathing

Mouth sores

Nasal congestion

Nasal drainage

Nasal polyps

Nosebleeds

Post-nasal drip

Sinus congestion

Sneezing

Snoring

Sore throat

Stridor

Throat tightness

Other

Other (specify)

Speech

Delay/Impediment

Slurred

Stuttering

Other

Other (specify)

Heart

Chest pain

Dizziness

Murmurs

Fainting spells

Irregular heartbeat

Palpitations

Other

Other (specify)

Lungs

Chest tightness

Cough-nonproductive/dry

Cough productive (phlegm)

Cough at night

Coughing up blood

Frequent bronchitis/chest colds

Wheezing

Shortness of breath-daytime

Shortness of breath-nighttime

Shortness of breath-exercise or vigorous play

Low oxygen levels

Other

Other (specify)

Abdominal pain/stomach ache

Bloody stool

Bloating

Burping

Choking on food/drink

Constipation

Diarrhea

Gassiness

Heartburn/acid taste in mouth

Indigestion

Nausea

Vomiting

Regurgitation/spitting up

Trouble swallowing

Other

Other (specify)

Feeding and Nutrition

Do you have any concerns about your child's weight or height?

Weight loss

Poor weight gain

Too short

Too thin

Overweight

Does the child have?

Difficulty feeding?

Yes

Loss of appetite?

Yes

Food avoidance?

Yes

If yes, does the child avoid or refuse particular foods?

Milk

Egg

Wheat

Soy

Peanut

Tree nuts

Fish

Shellfish

Other

Others

Does the child avoid certain textures or type of foods?

Soft/mushy texture

Crunchy texture

Bolus foods(e.g meats/breads)

Spicy foods

Others

Does the child cough or choke/gag when eating or drinking?

Liquids

Yes

Solids

Yes

Others

Skin

Easy brusing

Eczema

Hair loss

Hives/wells

Infections

Itching

Lumps

Rashes

Other

Other (specify)

Blood Diseases

Anemia

Easy bruising

Bleeding tendency

Hemophilia

Sickle Cell Anemia

Other

Other (specify)

Sleep

Excessive daytime sleepiness

Difficulties falling asleep

Multiple night awakenings

Frequent or loud snoring

Stopping breathing during sleep

Morning headaches

Restless sleep (kicking, jerking, twitching)

Difficulty waking in the morning

Discomfort or pain in legs at bedtime/during the night

Other

Other (specify)

MEDICATIONS

What medications does your child take?

Steroid Inhalers

Asmanex

Azmacort

Alvesco

Aerobid

Flovent HFA OR DISKUS

Pulmicort Flexhaler

Pulmicort/Budesonide Respule

Qvar

Other

Fast-acting Inhalers

Albuterol

Ventolin

Atrovent

Proair

Xopenex

Combivent

Other

Long-acting Bronchodilators

Spiriva

Incruse

Combination Medications (Inhaled Steroid and Long Acting Bronchodilator)

Advair HFA

Advair DISKUS

AirduoDISKUS

Symbicort HFA

Dulera HFA

Wixela

Trelegy

Breo

Other

Leukotriene Modifying Agents

Singulair

Accolate

Zyflo

Oral Steroids

Prednisone, Deltasone, Medrol

Prelone, Pediapred, Orapred

Other Medications

Theophylline

Xolair

Allergy Shots

Biologic

Other

Antihistamines

Allegra

Benadryl

Hydroxyzine

Clarinex

Claritin

Xyzal

Zyrtec

Other

Nose Spray

Saline

Asteline

Flonase

Nasacort AQ

Nasonex

Rhinocort AQ

Veramyst

Zantac/Ranitidine

Proton pump inhibitors

Epipen

Other

NOTICE OF PRIVACY PRACTICES*

We Care About Your Privacy

SUGAR LAND ALLERGY, ASTHMA &
IMMUNOLOGY CENTER, P.A.
4820 Sweetwater Blvd.
Sugai Land, TX 77479
Telephone: (281) 494,4600

Our Pledge Regarding Medical Information

The privacy of your medical information is important to us, We understand that your medical information is personal and we are committed to protecting it. We create a record of the care and services you receive at our organization. We need this record to provide you with quality care and to comply with certain legal requirements. This notice will tell you about the ways we may use and share medical information about you. We also describe your rights and certain duties we have regarding the use and disclosure of medical information.

Our Legal Duty

Law Requires Us to:

Keep your medical information private.
Give you this notice describing our legal duties, privacy practices, and your rights regarding your medical information.
Follow the terms of the current notice.

We have the Right to:

Change our privacy practices and terms of this notice at any time, provided that the changes are permitted by the law.
Make the changes in our privacy practices and the new terms of our notice effective for all medical information that we keep, including information previously created or received before the changes.

Notice of Change to Privacy Practices:

Before we make an important change in our privacy practices, we will change this notice and make the new notice available upon request.

Use and Disclosure of your Medical Information

The following section describes different ways that we use and disclose medical information, Not every use or disclosure will be listed. However, we have listed all of the different ways we are permitted to use and disclose medical information. We will not use or disclose your medical information for any purpose not listed below, without your specific written authorization. Any specific written authorization you provide may be revoked at any time by writing to us.

For Treatment:
We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other people who are taking care of you. We may also share medical information about you to your other health care providers to assist them in treating you.

For Payment:
We may use and disclose your medical information for payment purposes. A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include your medical information.

For Health Care Operations:
We may use and disclose your medical information for our health care operations. This might include measuring and improving quality, evaluating the performance of employees conducting training programs, and getting the accreditation, certificates, licenses and credentials we need to serve you.

Additional Uses and Disclosures:
In addition to using and disclosing your medical information for treatment, payment, and health care operations, we may use and disclose medical information for the following purposes.

Facility Directory:
Unless you notify us that you object, the following medical information about you will be placed in our facility directories: your name; your location in our facility; your condition described in general terms; your religious affiliation, if any. We may disclose this information to members of the clergy or except for your religious affiliation, to others who contact us and ask for information about you by name.

Notification:
We may use and disclose medical information to notify or help notify: a family member, your personal representative or another person responsible for your care. We will share information about your location, general condition, or death. If you are present, we will get your permission if possible before we share, or give you the opportunity to refuse permission. In case of emergency, and if you are not able to give or refuse permission, we will share only the health information that is directly necessary for your health care, according to our professional judgment. We will also use our professional judgment to make decisions in your best interest about allowing someone to pick up medicine, medical supplies, x-ray or medical information for you.

Disaster Relief:
We may share medical information with a public or private organization or person who can legally assist in disaster relief efforts.

Fundraising:
We may provide medical information to one of our affiliated fundraising foundations to contact you for fundraising purposes. We will limit our use and sharing to information that describes you in general, not personal, terms and the dates of your health care. In any fundraising materials, we will provide you a description of how you may choose not to receive future fundraising communications.

Research in Limited Circumstances:
We may use medical information for research purposes in limited circumstances where the research has been approved by a review board that has reviewed the research proposal and established protocols to ensure the privacy of medical information.

Funeral Director, Coroner, Medical Examiner:
To help them carry out their duties, we may share the medical information of a person who has died with a coroner, medical examiner, funeral director, or an organ procurement organization.

Specialized Government Functions:
Subject to certain requirements, we may disclose or use health information for military personnel and veterans, for national security and intelligence activities, for protective services for the President and others, for medical suitability determinations for the Department of State, for correctional institutions and other law enforcement custodial situations, and for government programs providing public benefits.

Cout Orders and Judicial and Administrative Proceedings:
We may disclose medical information in response to a court or administrative order, subpoena, discovery request, or other lawful process, under certain circumstances. Under limited circumstances, such as a court order, warrant, or grand jury subpoena, we may share your medical information with law enforcement officials. We may share limited information with a law enforcement official concerning the medical information of a suspect, fugitive, material witness, crime victim or missing person. We may share the medical information of an inmate or other person in lawful custody with a law enforcement official or correctional institution under certain circumstances.

Public Health Activities:
As required by law, we may disclose your medical information to public health or legal authorities charged with preventing or controlling disease, injury or disability, including child abuse or neglect. We may also disclose your medical information to persons subject to jurisdiction of the Food and Drug Administration for purposes of reporting adverse events associated with product defects or problems, to enable product recalls, repairs or replacements, to track products or to conduct activities required by the Food and Drug Administration. We may also, when we are authorized by law to do so, notify a person who may have been exposed to a communicable disease or otherwise be at risk of contracting or spreading a disease or condition.

Victims of Abuse, Neglect, or Domestic Violence:
We may use and disclose medical information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may share your medical information if it is necessary to prevent a serious threat to your health or safety or the health or safety of others. We may share medical information when necessary to help law enforcement officials capture a person who has admitted to being part of a crime or has escaped from legal custody.

Workers Compensation:
We may disclose health information when authorized or necessary to comply with laws relating to workers compensation or other similar programs.

Health Oversight Activities:
We may disclose medical information to an agency providing health oversight for oversight activities authorized by law, including audits, civil, administrative, or criminal investigations or proceedings, inspections, licensure or disciplinary actions, or other authorized activities.

Law Enforcement:
Under certian circumstances, we may disclose health information to law enforcement officials. These circumstances include reporting required by certain laws (such as the reporting of certian types of wounds), pursuant to certain subpoenas or court orders, reporting limited information concerning identification and location at the request of a law enforcement official, reports regarding suspected victims of crimes at the request of a law enforcement official, reporting death, crimes on our premises, and crimes in emergencies.

Appointment Reminders:
We may use and disclose medical information for purposes of sending you appointment postcards or otherwise reminding you of your appointments.

Alternative and Additional Medical Services:
We may use and disclose medical information to furnish you with information about health-related benefits and services that may be of interest to you, and to describe or recommend treatment alternatives.

Your Individual Rights

You Have the Right to:

Look at or get copies of certain parts of your medical information. You may request that we provide copies in a format other than photo copies. We will use the format you request unless it is not practical for us to do so. You must make your request in writing. You may ask the receptionist for the form needed to request access. There may be charges for copying and for postage if you want the copies mailed to you. Ask the receptionist about our fee structure.
Receive a list of all the times we or our business associates shared your medical information for purposes other than treatment, payment, and health care operations and other specified exceptions.
Request that we place additional restrictions on our use or disclosure of your medical information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in the case of an emergency)
Request that we communicate with you about your medical information by different means or to different locations. Your request that we communicate your medical information to you by different means or at different locations must be made in writing to our Privacy Officer.
Request that we change certain parts of your medical information. We may deny your request if we did not create the information you want changed or for certain other reasons. If we deny your request, we will provide you with a written explanation. You may respond with a statement of disagreement that will be added to the information you wanted changed. If we accept your request to change the information, we will make reasonable efforts to tell others, including people you name, of the change and to include the changes in any future sharing of that information.
If you wish to receive a paper copy of this privacy notice, then you have the right to obtain a paper copy by making a request in writing to our Privacy Officer.

Questions and Complaints

If you have any questions about this notice, please ask the receptionist to speak to our Privacy Officer.
If you think we may have violated your privacy rights, you may speak to our Privacy Officer and submit a written complaint. To take either action, please inform the receptionist that you wish to contact the Privacy Officer or request a complain form. You may submit a written complaint to the U.S. Department of Health and Human Services; we will provide you with the address to file your complaint. We will not retaliate in any way if you choose to file a complaint.

*These privacy practices are currently in affect and will remain in effect untill further notice.

Patient Instruction/Consent Form for Allergy Skin Testing

Skin Test: Skin tests are methods of testing for allergic antibodies. A test consists of introducing small amounts of the suspected substance, or allergen, into the skin and noting the development of a positive reaction (which consists of a wheal, swelling, or flare in the surrounding area of redness). The results are read at 15 to 20 minutes after the application of the allergen. The skin test methods are:

Prick Method: The skin is pricked with a needle where a drop of allergen has already been placed.

lntradermal Method: This method consists of injecting small amounts of an allergen into the superficial layers of the skin.

Interpreting the clinical significance of skin tests requires skillful correlation of the test results with the patient's clinical history. Positive tests indicate the presence of allergic antibodies and are not necessarily correlated with clinical symptoms.

You will be tested to important (location) airborne allergens and possibly some foods. These include, trees, grasses, weeds, molds, dust mites, and animal danders and, possibly some foods. Prick (also known as percutaneous) tests are usually performed on your arms or back. lntradermal skin tests may be performed if the prick skin tests are negative and are performed on your arms. If you have a specific allergic sensitivity to one of the allergens, a red, raised, itchy bump (caused by histamine release into the skin) will appear on your skin within 15 to 20 minutes. These positive reactions will gradually disappear over a period of 30 to 60 minutes, and, typically, no treatment is necessary for this itchiness. Occasionally local swelling at a test site will begin 4 to 8 hours after the skin tests are applied, particularly at sites of intradermaltesting. These reactions are not serious and will disappear over the next week or so. They should be measured and reported to your physician at your next visit. You may be scheduled for skin testing to antibiotics, caines, venoms, or other biological agents. The same guidelines apply.

PRECAUTIONS

No prescription or over the counter oral antihistamines should be used 4 to 5 days prior to scheduled skin testing. These include cold, cough and sinus medications, hay fever medications, or oral treatments for itchy skin,over the counter allergy medications, such as Claritin, Zyrtec, Allegra, Actifed, Dimetapp, Benadryl, hydroxyzine (Atarax), and many others. Prescription antihistamines such as Clarinex and Xyzol should also be stopped at least 5 days prior to testing. If you have any questions whether or not you are using an antihistamine, please ask the nurse or the doctor. In some instances a longer period of time off these medications may be necessary.
You should discontinue your nasal and eye antihistamine medications, such as Patanase, Pataday, Astepro, Optivar, or Astelinup to 5 days before the testing. In some instances a longer period of time off these medications may be necessary. If you have any questions whether or not you are using an antihistamine, please ask the nurse or the doctor. In some instances a longer period of time off these medications may be necessary.
3.Medications such as over the counter sleeping medications (e.g. Tylenol PM) and other prescribed drugs, such as amytriptyline hydrochloride (Elavil), doxepin (Sinequan), and imipramine (Tofranil) have antihistaminic activity and should be discontinued at least 2 weeks prior to receiving skin test after consultation with your physician. Please make the doctor or nurse aware of the fact that you are taking these medications so that you may be advised as to how long prior to testing you should stop taking them. If you are taking antidepressants, psychotropic or anitreflux medications, they may have antihistaminic properties and should be discussed with the doctor prior to testing.

YOU MAY

You may continue to use your intranasal allergy sprays such as Flonase Rhinocort, Nasonex, Nasacort,Omnaris, Veramyst and Nasarel.
2.Asthma inhalers (inhaled steroids and bronchodilators) and oral theophylline (Theo Dur,T-Phyl, Uniphyl, Theo-24, etc.) donot interfere with skin testing and should be used as prescribed. Leukotriene antagonists (e.g. Singulair, Accolate) should be held the night before testing.
Most drugs do not interfere with skin testing but make certain that your physician and nurse know about every drug you are taking (bring a list if necessary).

Skin testing will be administered at this medical facility with a medical physician or other health care professional present since occasional mild or very rare severe reactions may require immediate therapy. Talk to your doctor about any further details. Please let the physician and nurse know if you are pregnant or taking beta-blockers. Allergy skin testing may be postponed until after the pregnancy in the unlikely event of a reactions to the allergy testing and beta blockers are medications they may make the treatment of the reaction to skin testing more difficult.

Please note that reactions rarely occur but in the event a reaction would occur, the staff is fully trained and emergency equipment is available.

After skin testing, you will consult with your physician or other health care professional who will make further recommendations regarding your treatment.

Please do not cancel your appointment since the time set aside for your skin test is exclusively yours for which special allergens are prepared.If for any reason you need to change your skin test appointment, please give us at least 48 hours notice, due to the length of time scheduled for skin testing, a last minute change results in a loss of valuable time that another patient might have utilized.

I have read the patient information sheet on allergy skin testing and understand it.The opportunity has been provided for me to ask questions regarding the potential side effects of allergy skin testing and these questions have been answered to my satisfaction.I understand that every precaution consistent with the best medical practice will be carried out to protect me against such reactions.

Patient Name(Required)

Date:(Required)

MM slash DD slash YYYY

Patient or legal guardian Signature(Required)

*as parent or legal guardian, I understand that I must accompany my child throughout the entire procedure and visit.

Dear Patients:

As your trusted source of allergy and asthma care, we want to introduce you to our newest medical device designed to better diagnose and monitor your asthma. Along our continuous search for the latest technology, we found the NIOX MINO® Airway Inflammatory Monitoring System. Along with the tools we currently use to look at how successful pharmaceutical therapy has been, the NIOX MINO will be an additional measure that tells us your level of lung inflammation. The device employs an easy and non-invasive method of a simple 10 second exhalation that you will find completely painless and even a little fun.

Just a few of the many benefits of this new technology are:

The possibilities of lowering your dose of medication when appropriate
The ability to adjust medication based on your individual needs
Insight into your treatments efficacy
Better prediction of asthma relapse and exacerbation
Early identification and close monitoring or airway inflammation

We value your trust in us and will continue to offer the most sensitive and accurate ways to best control your asthma and its symptoms.

Please note: If the test is performed, we will bill your insurance provider for the appropriate charge. If the charge is not covered, you may receive a bill for $20.00 to cover the medical costs of performing this sensitive measurement. If you do not wish to be charged for this test please notify the staff prior to performing the test.
Thank you!

Patient Name(Required)

Date:(Required)

MM slash DD slash YYYY

Patient or legal guardian Signature(Required)

Patient agrees to accept charges if not covered by their insurance provider Initial:

This field is for validation purposes and should be left unchanged.

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