Allergy & Asthma Specialty Services, P



Allergy & Asthma Specialty Services, P. S.

W. Pierre Andrade, M.D. James S. Brown, M.D. T. Ted Song, D.O. Kristi McKinney, M.D. Jennifer Cole, D.O.

Office Addresses & Shot Hours

Lakewood Office: 11203 Bridgeport Way S.W.

Lakewood, WA 98499

Phone: (253)589-1380

Monday/Thursday 730am-1130am/1-6pm Tuesday 730am-1130am/1pm-430pm

Saturday 730am-1130am

Puyallup Office: 318 39th Ave S.W., Suite B

Puyallup, WA 98373

Phone: (253)589-1380

Monday/Thursday 730am-1130am/1-6pm Tuesday 730am-1130am/1pm-430pm

Gig Harbor Office: 4700 Point Fosdick Dr. NW, Suite 310

Gig Harbor, WA 98335

Phone: (253)589-1380

Monday/Thursday 730am-1130am/1pm-6pm Tuesday 730am-1130pm/1pm-430pm

Olympia Office: 3920 Capital Mall Drive SW, Suite 304

Olympia, WA 998502

Phone: (253)589-1380

*If you use GPS Capital must be spelled: CAPITOL MALL DRIVE

* Please feel free to utilize the free valet parking service located at the front entrance of Capital Medical Center, otherwise allow time for parking!

Monday, Tuesday and Thursday 830am-1230pm 130pm – 500pm

Allergy and Asthma Specialty Services, P.S.

W. Pierre Andrade, M.D. James S. Brown, M.D. T. Ted Song, D.O. Kristi McKinney, M.D. Jennifer Cole, D.O.

ALLERGY WORKSHEET

|NAME: |AGE: |BIRTHDATE: |DATE: |

|HOME ADDRESS: |PHONE: |

|HISTORY: (for physician only) |

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|Have you ever been hospitalized or visited an Emergency Room for your symptoms? Yes No |

|When? |

|Do you notice any association between symptoms and any Foods, Medications, or |Do you take any products such as aspirin, laxatives, health foods, or vitamins? |

|anything you apply to your body? (If yes, please list) | |

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|CHECK YOUR MAIN SYMPTOMS BELOW: |

|ο blocked nose ο bad breath ο red eyes ο skin rash ο chest pain |

|ο itchy nose ο post nasal drip ο itchy eyes ο faintness ο palpitations (heart flutter) |

|ο runny nose ο facial pain ο watery eyes ο unconsciousness ο diarrhea |

|ο sneezing ο blocked ears ο headache ο shortness of breath ο stomach pain |

|ο poor sense ο itchy ears ο frequent colds ο wheezing ο stomach cramp of smell ο eczema ο swelling ο chronic cough ο |

|others |

|ο discolored ο itching ο hives ο night cough |

|nasal mucus ο welts ο tightness of the chest |

|When did symptoms first appear? | What time of year is worse?(Which months): |

|Check those factors below which cause or increase your symptoms: |

|οAir conditioning οDust, indoors οFlowers, trees οPaint, varnish οTobacco smoke |

|οAir pollution οDust, outdoors οGrasses, weeds οPets, other animals οWinds, drafts |

|οAspirin οExertion οIndustrial fumes οPregnancy οWorry, tension |

|οBright lights οFabrics οInsecticides οRain, dampness οSun |

|οColds, flu οFeathers οMenses οSoaps, detergents οVibration |

|οCosmetics, perfumes οFireplace smoke οNewsprint οTemperature change οOther |

|οHeat |

|Medications you have taken for this problem: Did any help? |

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ALLERGY WORKSHEET (Con’t)

|NAME: |AGE: |BIRTHDATE: |DATE: |

| Have you had allergy tests before? |

|ο YES ο NO If yes, where was the testing done? |

|Have you taken allergy shots? |Did Shots Help? |

|ο YES ο NO If yes, number of years? _____ Year Stopped____ |YES ο NO ο |

| Do you have a food allergy? ο YES ο NO If yes, which foods? |

| Do you have a drug allergy? ο YES ο NO If yes, which drugs? |

| Do you have an allergy to insects? ο YES ο NO If yes, which insects? |

| Is there any family history of? |# of Cesarean? ____ |

|Allergies? ο Yes ο No Who? |# of Pregnancies? ____ |

|Asthma? ο Yes ο No Who? |# of Living Children? ____ |

|Eczema? ο Yes ο No Who? |# of live births? ____ |

| |# of still births? ____ |

| |# of Miscarriages? ______ |

|Do you have any of the following symptoms? (check any that apply) |

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|ο Fever ο Problems with your skin ο Problems with your blood |

|ο Problems with your digestive system ο Problems with your bones or joints ο Dental problems |

|ο Problems with your urinary tract ο Problems with your heart ο “Heartburn” |

|ο Weight Loss ο Problems with your nervous system ο Swollen lymph nodes or other masses |

|ο Other: |

|Please list current medications you are taking and date you started them: |

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| Check any diseases or surgeries you may have had: |

|οsinus surgery οtonsillectomy οmigraine οtuberculosis οhiatus hernia οseizure/epilepsy |

|οsinus infection οadenoidectomy οkidney disease οheart disease οpneumonia οbronchitis |

|οpolyp removal οear surgery οhypertension οglaucoma οliver disease οhysterectomy οnose surgery οarthritis οcancer οdiabetes οappendectomy |

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|List any other medical diagnosis or surgeries: |

| How long have you lived in Washington State? _________________________________ |

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|Where did you grow up? _________________________Where did you live before Washington State? ___________________ |

| Do you smoke? ο Yes ο No |Do you have pets? ο Yes ο No |

|If yes, how much? __________ |Are they indoor or outdoor pets? |

|If you have quit smoking, |List type of pets: |

|How many years did you smoke? | |

|Do others smoke at home? ο Yes ο No |Where do pets sleep? ______________________ |

|When did you quit? | |

|What is your occupation? |Home Location |

| |οRural οNear Freeway |

|Work location? Indoors Outdoors |οSuburbs οNear Farming |

| |οNear Industry οUrban |

| Home Heating System: Bedroom | Bedroom |

|οGas οElectric οIn wall heaters |οCarpeting οIndoor plants |

|οBaseboard οForced Air |οFeather bedding |

|οRadiant Heat οWoodstove |Mattress Type |

|οFireplace οHeat Pump |οInnerspring οFoam |

|οOil οRadiant |οWaterbed οFuton |

Allergy & Asthma Specialty Service, P.S.

W. Pierre Andrade, M.D. James S. Brown, M.D. T. Ted Song, D.O. Kristi McKinney, M.D. Jennifer Cole, D.O.

Current List Of Medications

|Name: | |Birthday: | |Date: | |

|Staff Processing: | |Pharmacy: | |Pharmacy #: | |

Please note that it is important for the Allergist to know your current medications you are taking and the date you started to take them. This way the Allergist can check if there are any drug interactions.

|# |Name of Medication |Strength |How Often Taken |Prescribed by Who |Date Started |

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ALLERGY AND ASTHMA SPECIALTY SERVICE, P.S.

Common Medications to Avoid Prior to Testing

Patients please note: Antihistamines and other medications can affect how patients respond to allergy testing. The medications that affect skin testing are antihistamines, some antidepressant and GI medications called H2 blockers. You should not stop any other medication(s) you are taking that have been prescribed by your doctor(s). It is impossible to have a complete list of antihistamines, so always review your medications to see if they contain antihistamines.  Herbal medications may contain antihistamines as well.

Here is a list of common medications that can affect response to skin testing:

|1. Prescription Antihistamines – DO NOT TAKE 72 HOURS PRIOR TO TESTING |

|Actidil (triprolidine) |Brocon |Dytuss |Historal |Nolamine |Rynatan |

|ADAC |Citra |Extendryl 4-Way cold tab |Hycomine |Optimine |Rynatuss |

|Albatussin |Co-Pyronil |Fedahist |Isoclor |PBZ |Seprex –D |

|Ambenyl |Codimal |Fedrazil |Kronofed –A |Periactin – (cyproheptadin) |Sinulin Tablets |

|Anamine |Comhist |Fiogesic |Kronofed –A Jr. |Phenergan-(promethazine) |Tacaryl |

|Atrohist Ped. |Comtrex |Disophrol |Meclizine |Protid |Tavist – (Clemestine) |

|Atrohist plus Tablets |Contac |Hispril |Naldecon |Quelidrine |Trinolin |

|Azatadine |Dextratussin |Histabid |Napril |Rhinex |Tussionex |

|Bomfed Capsules |Dura-Vent DA |Histadyl |Neotep |Rhondec | |

|Brexin |Duratap Pd |Histopan |Nolahist Tablets |Ru-Tuss | |

|2. Over the Counter Antihistamines – DO NOT TAKE 72 HOURS PRIOR TO TESTING |

|Actifed |Cerose DM |Dimetane |Ryna-12 |Sominex |Triaminic |

|Alka-Seltzer Cold |Chlor-Trimeton |Dimetapp |Ryna-C |Sudafed Cold & Allergy |Triaminicol |

|Alka-Seltzer Flu |Chlorpheniramine |Dristan |Ryna-C Liquid |Sudafed Plus |Tussi-12 |

|Alka-Seltzer Night |Comtrex Allergy–Sinus |Drixoral |S-T Forte |Tanafed |Tylenol Allergy |

|Alka-Seltzer PLUS |Comtrex Cold & Flu |Excedrin PM Cough & Cold |Singlet |Tavist D |Tylenol Cold |

|Alka-Seltzer Sinus |Contact-Allergy |Herbal Allergy Med. |Sinovan |Teldrin Allergy |Tylenol Flu |

|Aller-Chlor |Coridcidin Cough |Formula 44 |Sine-Aid |Thera-Flu |Tylenol PM |

|Allerest |Coricidin D |Mescolor |Sine-Off Cold |Thera-Flu Cold |Tylenol Sinus |

|BC Allergy |Coricidin Night-Time |Nyquil |Sine-Off Sinus |Thera-Flu Sinus |Vicks Formula 44 |

|Benadryl - |DA Chewables |Pedia-Care |SinuTab | |***All Sleep Aides*** |

|(Diphenhydramine) |Deconamine | |Sinus Cold Powder | | |

|3. Antihistamines – DO NOT TAKE 10 DAYS PRIOR TO TESTING |

|Allegra - (fexofenadine HCL) |Clarinex - (desloratadine) |Palgic – (carbinoxamine maleate) |Vistaril - (hydroxyzine) |Zyrtec - (cetirizine HCL) |

|Atarax - (hydroxyzine) |Claritin - (loratadine) |Seldane - (tertenadine) |Xyzal – (levocetirizine) | |

|4. Antihistamines – DO NOT TAKE 2 MONTHS PRIOR TO TESTING : Hismanal - (astemizole) |

|5. Nasal Sprays with Antihistamines – DO NOT TAKE 72 HOURS PRIOR TO TESTING |

|Astelin |Astepro |Azelastine |Dymista |Patanase |

|6. Eye Drops with Antihistamines – DO NOT TAKE 72 HOURS PRIOR TO TESTING **Any over the counter allergy eye drops that may contain antihistamines.** |

|Alvalon-A |Lastacaft (alcaftadine) |Pataday |Patanol |Vasacon-A |

| |Livostin | |Systane |Zaditor |

|7. Eye Drops with Antihistamines – DO NOT TAKE 48 HOURS PRIOR TO TESTING: Optivar Eye drop-( azelastine ) |

|8. Anti-Itch Creams with Antihistamines – DO NOT TAKE 24 HOURS PRIOR TO TESTING |

|Cortaid |Triamcinolone cream |Gold Bond |Lanacane |

|9. Muscle Relaxers – DO NOT TAKE 72 HOURS PRIOR TO TESTING |

|Cyclobenzaprene – (Flexeril) |

|10. Antidepressants & Tranquilizers – IF POSSIBLE DO NOT TAKE 72 HOURS PRIOR TO TESTING |

|**Always ask your doctor prior to stopping any antidepressants or tranquilizers.** |

|Abilify |Deprol |Ludiomil |Nisequan |Pertofrane |Surmontil |

|Acendir |Doxepin (Sinequam) |Lumbitrol |Norpramin |Remeron (Mirtazapine) |Tofranil |

|Adepin |Elavil |Nardil |Pamelor |Risperdal |Triavil |

|Amitriptyline |Endep |Marplan |Parnate |Seroquel |Vivactil |

|Arentyl |Etroafon | | | | |

|11. Antidepressants & Tranquilizers – IF POSSIBLE DO NOT TAKE 10 DAYS PRIOR TO TESTING Antivert (Meclizine) |

|**Always ask your doctor prior to stopping any antidepressants or tranquilizers.** |

|12.  H2 blockers (also sometimes referred to as acid reducers or H2 receptor antagonists) are available in nonprescription and prescription forms. IF POSSIBLE DO NOT |

|TAKE 3 DAYS PRIOR TO TESTING Brand and generic name: |

|Axid |Zantac |Pepcid |Tagamet | | |

|Generic: nizatidine |Generic: Ranitidine |Generic: famotidine |Generic: cimetidine | | |

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W. Pierre Andrade, MD James S. Brown, MD T. Ted Song, DO Kristi McKinney, M.D. Jennifer Cole, D.O.

Patient Information Form 2017 (Please Print Clearly)

| |New Patient | |2. Information changed: | |

|Allergy shot patients enter tray #(s): | |Date: ____________ |Location: _______________ |

|Patient Information |Guarantor Information (Parent/Guardian of Minor) |

|Last Name: | |Last Name: | |

|First Name: | |First Name: | |

|M.I.: | |M.I.: | |

|DOB: | |DOB: | |

|DL#: | |DL#: | |

|Gender: | |Gender: | |

|Home Phone #: | |Home Phone #: | |

|Work Phone #: | |Work Phone #: | |

|Cell Phone #: | |Cell Phone #: | |

|Address: | |Address: | |

|City: | |City: | |

|State/Zip: | |State/Zip: | |

|Employer: | |Employer: | |

|Email: | |Email: | |

|Marital Status: | |Marital Status: | |

|Allergist: | | Relation to Patient: | |

|Referring Dr.: | |Patient Number: | |

|PCP: | |Emergency Contact: | |

Do you consider yourself to be of Hispanic or Latino ethnicity? ( Yes ( No ( Decline to answer

|What is your primary race? | |

| |American Indian or Alaska Native | | |English | |

| |Asian | | |Spanish | |

| |Black or African American | | |American Sign Language | |

| |Native Hawaiian or other Pacific Islander | | |Russian | |

| |White/Caucasian | | |Korean | |

| |Other | | |Other | |

| |Decline to answer | | |Decline to answer | |

|Insurance Information (Patient must provide all insurance cards at time of visit) |

| |Primary Insurance |Secondary Insurance |Other Insurance |

|Insurance Name: | | | |

|Name of Policy Holder: | | | |

|Subscriber ID#: | | | |

|Group #: | | | |

|Co-Pay Required: | | | |

|Policy Holder’s Sex: | | | |

|Policy Holder’s Date of Birth: | | | |

|Relationship to Patient: | | | |

|Insurance Effective Date: | | | |

|Insurance Provider Phone #: | | | |

| |

ASSIGNMENT OF INSURANCE BENEFITS

I hereby authorize and request my insurance company to pay directly to the doctor the amount(s) due on my claim for services rendered to me or my dependent. I further agree that should the amount be insufficient to cover the entire medical expense, I will be responsible for the payment of the difference; and if the nature of the disability be such that it is not covered by the policy, I will be responsible to the doctor for the payment of the entire bill.

Patient’s or Guarantor’s Signature:_______________________________ Relationship to patient: ( Self

(Parent/Legal Guardian

Print name of signature above: __________________________________ ( Other: _____________________

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Paperwork for New Patients

|Last Name: | |First Name: | |

|Appt Date: | |Appt Time: | |

|Name of Receptionist Preparing Paperwork: | |Date Mailed: | |

Date: January 11, 2017

Dear

Welcome to our office! Below you will find some information that will be helpful for you.

Be aware that we will not know if the doctor will be ordering any tests on your first visit. (Check the

list of medications you need to avoid that is included in this packet). The doctor will make the decision after evaluating your medical problem. In case you are tested you need to be prepared with the following:

• Please wear a loose, short-sleeved shirt so the nurse can access your arms for testing.

• Testing appointments usually run about 2 ½ hours.

Please fill out the forms that are included in this packet and bring them to your first appointment.

• Please arrive 15 minutes prior to your appointment time so that the receptionist can go over the paperwork and get you checked in.

• Please refrain from using any fragrance or fragrant lotions as they can cause allergy or asthma symptoms to patients and staff. Do wear comfortable clothing.

• We recommend you do not bring small children to your testing appointment as it may be difficult for them due to the length of the testing process.

• Please bring all your medical insurance cards and photo ID to your first appointment.

• Copays are an agreement between you and your medical insurance and they need to be paid at the time of service. Please come prepared to pay this at your visit with us or there will be a

$10 service fee added on to the copay amount.

• Provider One and HMO plan patients: You need to bring your Provider One and HMO card to the first office visit or allergy shot of each month.. Your Provider One card requires us to check your benefits on a monthly basis.

ALLERGY & ASTHMA SPECIALTY SERVICE, P.S.

Thank you for choosing Allergy & Asthma Specialty Service (AASS) for your medical care.

Financial Responsibility:

• Patients must arrive at their scheduled appointment with their insurance card(s), photo ID and insurance copay if applicable. Copays required by a patient’s insurance must be paid at the time of the appointment. A $10 service fee may be applied when the copay is not paid at the time of the appointment. This service fee is in addition to the copay amount owed.

• If a patient’s insurance plan requires a referral to be seen at a specialist’s office, it is the patient’s responsibility to ensure a referral is on file and is current for all dates of service. If no referral is on file, the patient may be responsible for the total amount of service provided. Patient balances must be paid within 30 days of receipt of the patient statement.

• Patients who do not have insurance coverage (private pay) are required to pay a minimum deposit of $200/$150 (new/established patient) at the time of their appointment check in. This deposit amount does not cover the entire cost of the services provided. The balance remaining will be billed to patient and is payable within 30 days of receipt of the patient statement. If paid in full at the time of the appointment, there will be a 20% discount.

Late Cancellation and No Show Fee Policy:

• A late cancellation or no show fee of $25 will be charged to all patients who do not provide 24 hour notification to cancel a scheduled appointment or for patients who miss or no show their scheduled appointment. If a patient late cancels or no shows an appointment two times within a 12 month period, they may be discharged from the practice.

Treatment of a Minor (under the age of 18):

• If a patient is a minor, a parent/guardian or parents/guardians of the child must be present at the time of the new patient appointment. No exceptions. The parent is responsible for the patient’s copay and referral needs or other insurance requirements at the time of service for all scheduled appointments. AASS must have a signed consent form on file or a note signed by a parent or legal guardian if a parent or legal guardian does not accompany a minor to their future appointments.

Consent to Discuss Medical Care:

• Parents/Guardians of minor patients and all patients of legal age (18 years or older) will be asked to complete a Consent to Discuss Medical Care form. Completion of this form provides authorization for staff to discuss medical care with those individuals listed.

Health Insurance Portability and Accountability Act (HIPAA):

• I understand AASS will use and disclose health information about me in compliance with the HIPAA Act. I understand I am entitled to receive a copy of the Notice of Privacy Practices as outlined by federal regulations. I have the right to ask that some or all of my health information not be used or disclosed in the manner described in the Notice of Privacy Practices. I also understand AASS is not required by law to agree to such requests. My signature below acknowledges I am aware of my right in accordance to HIPAA.

• By signed this form, I acknowledge that I understand the policies as outlined above. In additions, my signature permits AASS to file claims to my insurance (if applicable). I also understand that I accept financial responsibility for all services rendered regardless of insurance coverage.

________________________________________________ __________________________

Signature of patient or parent/guardian Date

_________________________________________________ ________________________________

Printed name Patient name if different from signer

Allergy & Asthma Specialty Service, P.S.



Appointment Cancellation Policy

• Your appointment time is important to everyone.

• If you cannot keep your appointment for any reason, please call us at least 24 hours prior to your appointment time.

• If you miss your appointment or cancel with less than 24 hour’s notice, a fee of $25 may be charged to you.

• If you come unprepared to your appointment then a fee may be applied to your account.

• You are responsible for the payment of this fee; it will not be billed or paid by your insurance company.

• If a patient misses or late cancels an appointment twice within a 12 month period, his/her chart will be reviewed for possible discharge from the practice.

Thank you.

_________________________ _______________________

Signature Date of birth

_________________________ _______________________

Printed name Date

_________________________

Patient name if different from signer

Allergy & Asthma Specialty Service, P.S.

CONSENT TO DISCUSS MEDICAL CARE

Patient Name: (please print) __________________ Date of birth: _________________

I authorize Allergy & Asthma Specialty Service (AASS) to discuss my medical information with the following individuals I have listed below. Please print all names. You do NOT need to list physicians.

Name Date of birth Relationship

Name Date of birth Relationship

Name Date of birth Relationship

Name Date of birth Relationship

I give my permission for AASS to leave detailed medical information at my telephone number(s):

( ( ) ______-_________ ( ) ______-_________

( Or, I do not want detailed medical information left on any of my phone numbers.

________________________________ __________________________

(Signature of patient, parent or legal guardian) Date

______________________________________

Printed name of signature above

CONSENT FOR TREATMENT OF A MINOR

Established patients ONLY

Date: _____________

I, ____________________________, the parent/legal guardian of _____________________________,

Please print your name Please print patient’s name

__________________________ authorize and consent to routine and medical treatment for my child when deemed necessary by qualified medical personnel. This authorization is given in advance of any specific treatment being required and I waive my right of prior informed consent to such treatment. This authorization shall remain effective unless revoked in writing by me.

Signature of parent/guardian Date signed

• NOTE: For your child’s safety, AASS requires all children under the age of 16 to be accompanied by an adult (18years or older) for the duration of their visit when receiving allergy shots or being seen by the physician.

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