Patient Information. Name Address City State Zip Home# Cell # Business # SS# Patient s Relationship to Guarantor DOB / / Sex Occupation Employer

Transcription

1 Patient Information First MI Last SS# - - 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 address Preferred method of contact: Letter Phone call 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

2 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 worst (check all that apply): Spring Summer Fall Winter

3 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):

4 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 2. Effective Not effective 3. 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: 2. Drug: Date/Age: Reaction: 3. Drug: Date/Age: Reaction: 4. Drug: Date/Age: Reaction: 5. Drug: Date/Age: Reaction: 6. Drug: Date/Age: Reaction: 7. 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: 2. Food: Date/Age: Reaction: 3. Food: Date/Age: Reaction: 4. Food: Date/Age: Reaction: 5. Food: Date/Age: Reaction: 6. Food: Date/Age: Reaction: 7. Food: Date/Age: Reaction:

5 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: 2. Reason for taking: 3. Reason for taking: 4. Reason for taking: 5. Reason for taking: 6. Reason for taking: 7. Reason for taking: 8. Reason for taking: 9. Reason for taking: 10. Reason for taking: Please list all over the counter and herbal/vitamins that you are taking: 1. Reason for taking: 2. Reason for taking: 3. Reason for taking: 4. Reason for taking: 5. Reason for taking:

6 PAST MEDICAL HISTORY Operations/Surgery (Name and date of procedure) Hospitalizations (Where, reason, date, and length of stay) Medical Problems (Problem and date diagnosed) 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 (%): 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 (%): 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

7 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:

8 REVIEW OF SYSTEMS / ENVIRONMENTAL HISTORY 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 itching cough 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 To the best of my knowledge, I have answered the complete questionnaire. Signature Reviewed form with the patient in its entirety. Sean McKnight M.D. / Bob K. Miyake, M.D.

9 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. 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

10 NOTICE REGARDING PRIVACY OF PERSONAL HEALTH INFORMATION 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. Federal regulations developed under the Health Insurance Portability and Accountability Act (HIPAA) require that the Practice provide you with this Notice Regarding Privacy of Personal Health Information. The Notice describes (1) how the Practice may use and disclose your protected health information, (2) your rights to access and control your protected health information in certain circumstances, and (3) the Practices duties and contact information. I. Protected Health Information Protected health information is health information created or received by your health care provider that contains information that may be used to identify you, such as demographic data. It includes written or oral health information that relates to your past, present, or future mental health; the provision of health care to you; and your past, present, or future payment for health care. II. The Use and Disclosure of Protected Health Information in Treatment, Payment, and Health Care Operations Your protected health information maybe used and disclosed by the Practice in the course of providing treatment, obtaining payment for treatment, and conducting health care operations. Any disclosures may be made in writing, electronically, by facsimile, or orally. The Practice may also use or disclose your protected health information in other circumstances if you authorize the use or disclosure, or if state law or the HIPAA privacy regulations authorize the use or disclosure. Treatment. The Practice may use and disclose your protected health information in the course of providing or managing your health care as well as any related services. For the purpose of treatment, the Practice may coordinate your health care with a third party. For example, the Practice may disclose your protected health information to a pharmacy to fulfill a prescription for asthma medication, to an X-ray facility to order an X-ray, or to another physician who is administering your allergy shots, which we prepared. In addition, the Practice may disclose protected health information to other physicians or health care providers for treatment activities of those other providers. Payment. When needed, the Practice will use or disclose your protected health information to obtain payment for its services. Such uses or disclosures may include disclosures to your health insurer to get approval for a recommended treatment or to determine whether you are eligible for benefits or whether a particular service is covered under your health plan. When obtaining payment for your health care, the Practice may also disclose your protected health information to your insurance company to demonstrate the medical necessity of the care or for utilization review when required to do so by your insurance company. Finally, the Practice may also disclose your protected health information to another provider where that provider is involved in your care and requires the information to obtain payment. Healthcare Operations. The Practice may use or disclose your protected health information when needed for the Practice s health care operations for the purposes of management or administration of the Practice and of offering quality health care services. Health care operations may include: (1) quality evaluations and improvement activities; (2) employee review activities and training programs; (3)

11 accreditation, certification, licensing, or credentialing activities: (4) reviews and audits such as compliance reviews, medical reviews, legal services, and maintaining compliance programs; and (5) business management and general administrative activities. For instance, the Practice may use, as needed, protected health information of patients to review their treatment course when making quality assessments regarding allergy care or treatment. In addition, the Practice may disclose your protected health information to another provider or health plan for their health care operations. Other Uses and Disclosures. As part of treatment, payment, and healthcare operations, the Practice may also use or disclose your protected health information to: (1) remind you of an appointment; (2) inform you of potential treatment alternatives or options; or (3) inform you of health-related benefits or services that may be of interest to you. III. Additional Uses and Disclosures Permitted Without Authorization or An Opportunity to Object In addition to treatment, payment, and health care operations, the Practice may use or disclose your protected health information without your permission or authorization in certain circumstances, including: When Legally Required. The Practice will comply with any Federal, state, or local law that requires it to disclose your protected health information. When There Are Risks to Public Health. The Practice may disclose your protected health information for public health purposes, including to, as permitted or required by law: (1) Prevent, control, or report disease, injury, or disability; (2) Report vital events such as birth or death; (3) Conduct public health surveillance, investigations, and interventions; (4) Collect or report adverse events and product defects, track FDA regulated products, enable product recalls, repairs, or replacements, and conduct post marketing surveillance; (5) Notify a person who has been exposed to a communicable disease or who may be at risk of contracting or spreading a disease; and (6) Report to an employer information about an individual who is a member of the workforce. To Report Abuse, Neglect, or Domestic Violence. As required or authorized by law with the patient s agreement, the Practice may inform government authorities if it is believed that a patient is the victim of abuse, neglect, or domestic violence. To Conduct Health Oversight Activities. The Practice may disclose your protected health information to a health oversight agency for use in (1) audits; (2) civil, administrative, or criminal investigations, proceedings or actions; (3) inspections; (4) licensure or disciplinary actions; or (5) other necessary oversight activities as permitted by law. However if you are the subject of an investigation, the Practice will not disclose protected health information that is not directly related to your receipt of health care or public benefits. For Judicial and Administrative Proceedings. The Practice may disclose your protected health information for any judicial or administrative proceeding if the disclosure is expressly authorized by an order of a court or administrative tribunal as expressly authorized by such order or a signed authorization is provided.

12 For Law Enforcement Purposes. The Practice may disclose your protected health information to a law enforcement official for law enforcement purposes when: (1) Required by law to report of certain types of physical injuries; (2) Required by court order, court-ordered warrant, subpoena, summons, or similar process; (3) Needed to identify or locate a suspect, fugitive, material witness, or missing person; (4) Needed to report a crime in an emergency situation; (5) You are the victim of a crime in specific limited instances; and (6) Your death is suspected by the practice to be the result of criminal conduct. To Coroners, Funeral Directors, and for Organ Donation. The Practice may disclose protected health information to a coroner or medical examiner for the purpose of (1) identification, (2) determination of cause of death, or (3) performance of the coroner or medical examiner s other duties as authorized by law. In addition, as permitted by law, the Practice may disclose protected health information, including when death is reasonably anticipated, to a funeral director to enable the funeral director to carry out his or her duties. Protected health information may also be used and disclosed for the purpose of cadaveric organ, eye or tissue donation. For Research Purposes. The Practice may use or disclose your protected health information for research if such use or disclosure has been approved by an institutional review board or privacy board that has examined the research proposal and the research protocols which maintain the privacy of your protected health information. To Prevent or Diminish a Serious and Imminent Threat to Health or Safety. If in good faith the Practice believes that use or disclosure of your protected health information is necessary to prevent or diminish a serious and imminent threat to your health or safety or to the health and safety of the public, the Practice may use or disclose your protected health information as permitted under law and consistent with ethical standards of conduct. For Specified Government Functions. As authorized by the HIPAA privacy regulations, the Practice may use or disclose your protected health information to facilitate specified government functions relating to military and veterans activities, national security and intelligence activities, protective services for the President and others, medical suitability determinations, correctional institutions, and law enforcement custodial situations. For Worker s Compensation. The Practice may disclose your protected health information to comply with worker s compensation laws or similar programs. IV. Uses and Disclosures Permitted With an Opportunity to Object Subject to your objection, the Practice may disclose your protected health information (1) to a family member or close personal friend if the disclosure is directly relevant to the person s involvement in your care or payment related to your care; or (2) when attempting to locate or notify family members or others involved in your care to inform them of your location, condition or death. The Practice will inform you orally or in writing of such uses and disclosures of your protected health information as well as provide you with an opportunity to object in advance. Your agreement or objection to the uses and disclosures can be oral or in writing. If you do not object to these disclosures, the Practice is able to infer from the circumstances that you do not object, or the Practice determines, in its professional judgment, that it is in your best interests for the Practice to disclose information that is directly relevant to the person s involvement with your care, then the Practice may disclose your protected health information. If you are incapacitated or in an emergency situation, the Practice may exercise its professional judgment to determine

13 if the disclosure is in your best interests and, if such a determination is made, may only disclose information directly relevant to your health care. V. Uses and Disclosures Authorized by You Other than the circumstances described above, the Practice will not disclose your health information unless you provide written authorization. You may revoke your authorization in writing at any time except to the extent that the Practice has taken action in reliance upon the authorization VI. Your Rights You have certain rights regarding your protected health information under the HIPAA privacy regulations. These rights include: The right to inspect and copy your protected health information. For as long as the practice holds your protected health information, you may inspect and obtain a copy of such information included in a designated record set. A designated record set contains medical and billing records as well as any other records that your physician and the Practice uses to make decisions regarding the services provided to you. The Practice may deny your request to inspect or copy your protected health information if the Practice determines in its professional judgment that the access requested is likely to endanger your life or safety or that of another person, or that it is likely to cause substantial harm to another person referred to in the information. You have the right to request a review of this decision. In addition, you may not inspect or copy certain records by law, including: (1) information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding; and (2) protected health information that is subject to a law that prohibits access to protected health information. You may have the right to have a decision to deny access reviewed in some situations. You must submit a written request to the Practice s Privacy Officer to inspect and copy your health information. The Practice may charge you a fee for the costs of copying, mailing, or other costs incurred by the practice in complying with your request. Please contact our Privacy Officer if you have questions about access to your medical record at the number given on the last pages of this Notice. The right to request a restriction on uses and disclosures of your protected health information. You may request that the Practice not use or disclose specific sections of your protected health information for the purposes of treatment, payment, or health care operations. Additionally, you may request that the practice not disclose your health information to family members or friends who may be involved in your care or for notification purposes as described in this Notice. In your request, you must specify the scope of restriction requested as well as the individuals for which you want the restriction to apply. Your request should be directed to the Privacy Officer of the Practice. The Practice may choose to deny your request for a restriction, in which case the Practice will notify you of its decision. Once the Practice agrees to the requested restriction, the Practice may not violate that restriction unless use or disclosure of the relevant information is needed to provide emergency treatment. The Practice may terminate the agreement to a restriction in some instances. The right to request to receive confidential communications from the Practice by alternative means or at an alternative location. You have the right to request that the Practice communicates with you through alternative means or at an alternative location. The Practice will make every effort to comply with reasonable requests. However, the Practice may condition its compliance by asking you for information regarding the procurement of payment or specific information regarding an alternative address or other

14 method of contact. You are not required to provide an explanation for your request. Requests should be made in writing to the Privacy Officer of the Practice. The right to request an amendment of your protected health information. During the time that the Practice holds your protected health information, you may request an amendment of your information in a designated record set. The practice may deny your request in some instances. However, should the Practice deny your request for amendment, you have the right to file a statement of disagreement with the Practice. In turn, the Practice may develop a rebuttal to your statement. If it does so, the practice will provide you with a copy of the rebuttal. Requests for amendment must be submitted in writing to the Privacy Officer of the Practice. Your written request must supply a reason to support the requested amendments. The right to request an accounting of certain disclosures. You have the right to request an accounting of the Practice s disclosures of your protected health information made for purposes other than treatment, payment or health care operations as described in this Notice. The Practice is not required to account for disclosures (1) which you requested, (2) which you authorized by signing an authorization form, (3) for a facility directory, (4) to friends or family members involved in your care, and (5) certain other disclosures the Practice is permitted to make without your authorization. The request for an accounting must be made in writing to our Privacy Officer and should state the time period for which you wish the accounting to include, up to a six-year period. The Practice is not required to provide an accounting for disclosures that take place prior to April 14, The Practice will not charge you for the first accounting you request of any 12-month period. Subsequent accountings may require a fee based on the Practice s reasonable costs for compliance of the request. The right to obtain a paper copy of this Notice. The Practice will provide a separate paper copy of this Notice upon request even if you have already been given a copy of it or have agreed to review it electronically. VII. The Practice s Duties The Practice is required to ensure the privacy of your health information and to provide you with this Notice of your rights and the duties and procedures of the Practice regarding your privacy. The Practice must abide by the terms of this Notice, as may be amended periodically. The Practice reserves the right to change the terms of this Notice and to make the new Notice provisions effective for all protected health information that the Practice collects and maintains. If the Practice alters its Notice, the Practice will provide a copy of the revised Notice through regular mail or in-person contact. VIII. Complaints If you believe that your privacy rights have been violated, you have the right to relate complaints to the Practice and to the Secretary of the Department of Health and Human Services. You may provide complaints to the Practice verbally or in writing. Such complaints should be directed to the Privacy Officer of the Practice. The Practice encourages you to relate any concerns you may have regarding the privacy of your information and you will not be retaliated against in any way for filing a complaint.

15 IX. Contact Person The Practice s contact person regarding the Practice s duties and your rights under the HIPAA privacy regulations is the Privacy Officer. The Privacy Officer can provide information regarding issues related to this Notice by request. Complaints to the Practice should be directed to the Privacy Officer at the following address: Denise C. Yarborough Allergy Partners P.A. PO Box 2407 Skyland, NC The Privacy Officer can be contacted by telephone at: (828) X. Effective Date This notice is effective on April 14, 2003.

16 ACKNOWLEDGEMENT I, (patient) acknowledge that I have received a copy of Allergy Partners, P.A. d/b/a s Notice Regarding Privacy of Personal Health Information. Date: (Patient/Guardian Signature)

17 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: Actifed Advil PM, Advil Allergy, Advil Cold/Sinus Ala-Hist Alavert- All Forms Aleve Cold Alka Seltzer Plus/Cold Allegra- All Forms Allerest AlleRx- All Forms Allergy Relief Med Asteline Spray (Azelastine) Astepro Spray Atarax/Vistaril BC Cold Powder Benadryl Benylin Cough Med Bromfed- All Forms Brompheniramine Maleate Carbinoxamine Cetirizine HCL Chlorpheniramine Maleate Chlor-Trimeton- All Forms Clarinex- All Forms (Off 6 Days) Claritin- All Forms Comtrex Contac- All Forms Coricidin Co-Tylenol Cough Meds with Antihistamines Cyproheptadine Dimetane Dimetapp Diphenhydramine HCL- Check Label Dramamine Drixoral Dymista Excedrin PM Extendryl Fexofenadine- All Forms Hydroxyzine Pamoate/HCL Loratadine MylantaAR Night Time Sleep Aid Norel SR/DM Nytol Nyquil Patanase Nasal Spray Pediacare Percogesic Periactin Phenergan- All Forms Phenylephrine HCL Phenothiazines Phenyltoloxamine Polyhistine- All Forms Promethazine HCL Robitussin- Many Forms Rondec Rynatan/ R-Tannate Sinutab Sominex Sudafed Cold and Allergy Tagamet Tanafed Theraflu- All Forms Time-Hist Triaminic- All Forms Tussionex Tylenol Cold/Sinus/Allergy/Sleep Vistaril Vicks 44M Xyzal- All Forms Zantac Zicam Zyrtec- All Forms

18 Do not use oil, cream or lotion on the back or arms for 24 hours prior to skin testing. 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. Please call your local Allergy Partners office with any questions about these lists. Medical Services Provided by Allergy Partners, P.A.